Provider Demographics
NPI:1174644652
Name:LIBERATION PROGRAMS INC
Entity Type:Organization
Organization Name:LIBERATION PROGRAMS INC
Other - Org Name:LIBERATION MERIDIAN GUENSTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-851-2077
Mailing Address - Street 1:4 ELMCREST TER
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3908
Mailing Address - Country:US
Mailing Address - Phone:203-851-2077
Mailing Address - Fax:203-851-2082
Practice Address - Street 1:120 BROOKSIDE ROAD
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820
Practice Address - Country:US
Practice Address - Phone:203-655-8973
Practice Address - Fax:203-655-2389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0271261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004259025Medicaid