Provider Demographics
NPI:1801250956
Name:BOYS AND GIRLS VILLAGE, , INC.
Entity type:Organization
Organization Name:BOYS AND GIRLS VILLAGE, , INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IICAPS CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YEARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:203-690-5128
Mailing Address - Street 1:170 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2901
Mailing Address - Country:US
Mailing Address - Phone:203-330-6790
Mailing Address - Fax:203-330-6756
Practice Address - Street 1:170 BENNETT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2901
Practice Address - Country:US
Practice Address - Phone:203-330-6790
Practice Address - Fax:203-330-6756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health