Provider Demographics
NPI:1013362771
Name:SPECTRUM PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:SPECTRUM PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:203-695-4917
Mailing Address - Street 1:77-79 BISHOP STREET
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77-79 BISHOP ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-3306
Practice Address - Country:US
Practice Address - Phone:203-756-7987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2384251S00000X, 251S00000X
CT1113251S00000X
CT1600251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health