Provider Demographics
NPI:1477583581
Name:BOYS & GIRLS VILLAGE
Entity Type:Organization
Organization Name:BOYS & GIRLS VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:L.
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:FELLENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-877-0300
Mailing Address - Street 1:528 WHEELERS FARMS RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-1847
Mailing Address - Country:US
Mailing Address - Phone:203-877-0300
Mailing Address - Fax:203-876-0076
Practice Address - Street 1:528 WHEELERS FARMS RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-1847
Practice Address - Country:US
Practice Address - Phone:203-877-0300
Practice Address - Fax:203-876-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTEDT-10261QM0855X
CTOPCC-38261QM0855X
CTCPA-40261QM0855X
CTCCF/TS 17323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Not Answered323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004189173-00Medicaid