Provider Demographics
NPI:1285040675
Name:AUTHENTIC RECOVERY, LLC
Entity Type:Organization
Organization Name:AUTHENTIC RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIMONCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, MSW
Authorized Official - Phone:860-805-2267
Mailing Address - Street 1:37 SAW MILL RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-2001
Mailing Address - Country:US
Mailing Address - Phone:860-805-2267
Mailing Address - Fax:
Practice Address - Street 1:1 CARRIAGE PL
Practice Address - Street 2:SUITE 4
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2108
Practice Address - Country:US
Practice Address - Phone:860-805-2267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008047242Medicaid