Provider Demographics
NPI:1114061157
Name:FRIENDS AND FAMILY COUNSELING SERVICES
Entity Type:Organization
Organization Name:FRIENDS AND FAMILY COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELDA
Authorized Official - Middle Name:STOREY
Authorized Official - Last Name:CHESEBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LCSW
Authorized Official - Phone:860-572-4969
Mailing Address - Street 1:107 WILCOX ROAD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2613
Mailing Address - Country:US
Mailing Address - Phone:860-572-4969
Mailing Address - Fax:860-572-5767
Practice Address - Street 1:107 WILCOX ROAD
Practice Address - Street 2:SUITE 111
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-2613
Practice Address - Country:US
Practice Address - Phone:860-572-4969
Practice Address - Fax:860-572-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002410101YP2500X
CT0056491041C0700X
CT0078301041C0700X
CT001256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004256849Medicaid
CT12119967Medicare UPIN
CT11342489Medicare UPIN
CT392001Medicare UPIN
CT140005649CT02Medicare UPIN