Provider Demographics
NPI:1659542751
Name:CHILDREN OF THE WILDERNESS OUTREACH
Entity Type:Organization
Organization Name:CHILDREN OF THE WILDERNESS OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEWIS-TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-628-8096
Mailing Address - Street 1:71 NORFOLK ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2528
Mailing Address - Country:US
Mailing Address - Phone:203-628-8096
Mailing Address - Fax:203-931-8535
Practice Address - Street 1:71 NORFOLK STREET
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-479-5821
Practice Address - Fax:203-931-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT501C3282J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution