Basic Information
| Provider Information | |||||||||
| NPI: | 1659431518 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILD AND FAMILY GUIDANCE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066044252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033946529 | ||||||||
| FaxNumber: | 2033946534 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066044252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033946529 | ||||||||
| FaxNumber: | 2033946534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | GUZMAN | ||||||||
| AuthorizedOfficialFirstName: | L. PHILIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 2033946529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004039251 | 05 | CT | MEDICAID |