Provider Demographics
NPI:1154853307
Name:BOYS AND GIRLS VILLAGE
Entity Type:Organization
Organization Name:BOYS AND GIRLS VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IICAPS CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-980-4625
Mailing Address - Street 1:170 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 BENNETT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2901
Practice Address - Country:US
Practice Address - Phone:203-980-4625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10762370104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty