Provider Demographics
NPI:1659826048
Name:FAMILYWISE, LLC
Entity Type:Organization
Organization Name:FAMILYWISE, LLC
Other - Org Name:FAMILYWISE BEHAVIOR SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:860-642-7379
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-0026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 BROADWAY AVENUE EXT
Practice Address - Street 2:2C
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2850
Practice Address - Country:US
Practice Address - Phone:860-642-7379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT204714Medicaid