Provider Demographics
NPI:1558762807
Name:FAIRFIELD COUNTY CHILD AND ADOLESCENT THERAPY, LLC
Entity Type:Organization
Organization Name:FAIRFIELD COUNTY CHILD AND ADOLESCENT THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-260-1918
Mailing Address - Street 1:102 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2428
Mailing Address - Country:US
Mailing Address - Phone:203-260-1918
Mailing Address - Fax:
Practice Address - Street 1:34 SHERMAN CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5826
Practice Address - Country:US
Practice Address - Phone:203-260-1918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty