Provider Demographics
NPI:1689071417
Name:STALLWORTH COUNSELING SERVICES,LLC
Entity Type:Organization
Organization Name:STALLWORTH COUNSELING SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:203-568-5662
Mailing Address - Street 1:12 SNOW CRYSTAL RD
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-3527
Mailing Address - Country:US
Mailing Address - Phone:203-568-5662
Mailing Address - Fax:
Practice Address - Street 1:77 CHAPMAN AVE FL 3
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1309
Practice Address - Country:US
Practice Address - Phone:203-568-5662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health