Provider Demographics
NPI:1669731360
Name:FARMINGTON RIVER MENTAL HEALTH SPECIALISTS, LLC
Entity type:Organization
Organization Name:FARMINGTON RIVER MENTAL HEALTH SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-307-8943
Mailing Address - Street 1:46 W AVON RD STE 204
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3679
Mailing Address - Country:US
Mailing Address - Phone:860-307-8943
Mailing Address - Fax:860-824-1469
Practice Address - Street 1:46 W AVON RD STE 204
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3679
Practice Address - Country:US
Practice Address - Phone:860-307-8943
Practice Address - Fax:860-824-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X
CT0056931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty