Provider Demographics
NPI:1497295208
Name:BOYS AND GIRLS VILLAGE
Entity Type:Organization
Organization Name:BOYS AND GIRLS VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:475-414-6105
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:
Practice Address - Street 1:170 BENNETT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2901
Practice Address - Country:US
Practice Address - Phone:203-330-6790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health