Provider Demographics
NPI:1033239249
Name:SOUTHERN CT CHRISTIAN NETWORK
Entity Type:Organization
Organization Name:SOUTHERN CT CHRISTIAN NETWORK
Other - Org Name:SHORELINE CHRISTIAN COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ULARI
Authorized Official - Middle Name:
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-318-0700
Mailing Address - Street 1:145 DURHAM RD
Mailing Address - Street 2:MAILBOX 7
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2674
Mailing Address - Country:US
Mailing Address - Phone:203-318-0070
Mailing Address - Fax:206-339-8205
Practice Address - Street 1:145 DURHAM RD
Practice Address - Street 2:MAILBOX 7
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2674
Practice Address - Country:US
Practice Address - Phone:203-318-0070
Practice Address - Fax:206-339-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001460103TC0700X
CT0028761041C0700X
CT0048091041C0700X
CT0393012084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257269Medicaid
CT004257277Medicaid
CT307875OtherHEALTHNET-MHN
CT004257532Medicaid
CTC02421Medicare PIN