Provider Demographics
NPI:1912193418
Name:MIDWESTERN CONNECTICUT COUNSEL ON ALCOHOLISM
Entity Type:Organization
Organization Name:MIDWESTERN CONNECTICUT COUNSEL ON ALCOHOLISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OUT PATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE-BEECE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LADC
Authorized Official - Phone:203-792-4515
Mailing Address - Street 1:38 OLD RIDGEBURY RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5128
Mailing Address - Country:US
Mailing Address - Phone:203-792-4515
Mailing Address - Fax:
Practice Address - Street 1:38 OLD RIDGEBURY RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5128
Practice Address - Country:US
Practice Address - Phone:203-792-4515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCAC 4070251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health