Provider Demographics
NPI:1003960022
Name:SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE INC
Entity Type:Organization
Organization Name:SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE INC
Other - Org Name:SCADD INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-886-2495
Mailing Address - Street 1:37 CAMP MOOWEEN ROAD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249
Mailing Address - Country:US
Mailing Address - Phone:860-886-2495
Mailing Address - Fax:860-887-0007
Practice Address - Street 1:37 CAMP MOOWEEN ROAD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249
Practice Address - Country:US
Practice Address - Phone:860-889-1717
Practice Address - Fax:860-886-2361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0439261QM0850X
CT0343261QR0405X
CTSA0020324500000X
CTSA-0018324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004173671Medicaid
CT004042073Medicaid
CT004144606Medicaid
CT175904OtherMAGELLAN
CT149925OtherHEALTH NET