Provider Demographics
NPI:1134275647
Name:ADELBROOK COMMUNITY SERVICES, INC.
Entity type:Organization
Organization Name:ADELBROOK COMMUNITY SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-635-6010
Mailing Address - Street 1:58 MISSIONARY RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2134
Mailing Address - Country:US
Mailing Address - Phone:860-635-6010
Mailing Address - Fax:860-632-3216
Practice Address - Street 1:58 MISSIONARY RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2134
Practice Address - Country:US
Practice Address - Phone:860-635-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTOPCC-43251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004254736Medicaid