Provider Demographics
NPI:1184193591
Name:FULL CIRCLE YOUTH EMPOWERMENT
Entity Type:Organization
Organization Name:FULL CIRCLE YOUTH EMPOWERMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-400-2725
Mailing Address - Street 1:2310 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3241
Mailing Address - Country:US
Mailing Address - Phone:203-400-2725
Mailing Address - Fax:203-557-8901
Practice Address - Street 1:583-585 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608
Practice Address - Country:US
Practice Address - Phone:203-332-6200
Practice Address - Fax:203-332-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health