Basic Information
| Provider Information | |||||||||
| NPI: | 1942573431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE FOR FAMILIES AND CHILDREN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1680 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602364511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1680 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602364511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CULLEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | FRANCISCO | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8603427271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 000849 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.