Provider Demographics
NPI:1235755174
Name:CT MC SPROUT 1 LLC
Entity Type:Organization
Organization Name:CT MC SPROUT 1 LLC
Other - Org Name:SPROUT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:833-991-2368
Mailing Address - Street 1:101 MERRITT 7 FL PARK3
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1059
Mailing Address - Country:US
Mailing Address - Phone:833-991-2368
Mailing Address - Fax:929-384-7193
Practice Address - Street 1:101 MERRITT 7 FL PARK3
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1059
Practice Address - Country:US
Practice Address - Phone:833-991-2368
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty