Basic Information
| Provider Information | |||||||||
| NPI: | 1780730267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CHILD GUIDANCE CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606432101 | ||||||||
| FaxNumber: | 8606451470 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606432101 | ||||||||
| FaxNumber: | 8606451470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 05/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8606432101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 0238 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM0855X | OPCC-14 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004039277 | 05 | CT | MEDICAID |