Provider Demographics
NPI:1922574136
Name:SAUNDERS, DARRYL JEROME
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:JEROME
Last Name:SAUNDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GRILLEYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-2409
Mailing Address - Country:US
Mailing Address - Phone:203-802-7502
Mailing Address - Fax:
Practice Address - Street 1:22 CHASE RIVER RD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-1408
Practice Address - Country:US
Practice Address - Phone:203-753-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT101YA0400XMedicaid