Provider Demographics
NPI:1356831960
Name:CONNECTICUT COUNSELING CENTERS INC
Entity Type:Organization
Organization Name:CONNECTICUT COUNSELING CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INFORMATION SYSTEMS
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-568-7466
Mailing Address - Street 1:50 BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1402
Mailing Address - Country:US
Mailing Address - Phone:203-568-7466
Mailing Address - Fax:203-568-7468
Practice Address - Street 1:15 COMMERCE RD LOWR 1
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4553
Practice Address - Country:US
Practice Address - Phone:203-653-3808
Practice Address - Fax:203-653-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC0677261QM0850X
CTSA0567261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0677OtherCT DEPARTMENT OF PUBLIC HEALTH
CTSA0567OtherCT DEPTARTMENT PUBLIC HEALTH