Provider Demographics
NPI:1811906241
Name:ADOLESCENT & FAMILY COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:ADOLESCENT & FAMILY COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ROSENFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW, LCSW, BCD
Authorized Official - Phone:203-271-1234
Mailing Address - Street 1:350 S MAIN ST
Mailing Address - Street 2:THE REPUBLIC BUILDING / SUITE 23
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3160
Mailing Address - Country:US
Mailing Address - Phone:203-271-1234
Mailing Address - Fax:203-272-9094
Practice Address - Street 1:350 S MAIN ST
Practice Address - Street 2:THE REPUBLIC BUILDING / SUITE 23
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3160
Practice Address - Country:US
Practice Address - Phone:203-271-1234
Practice Address - Fax:203-272-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X, 103TS0200X, 106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7348011OtherAETNA HEALTH MANAGEMENT
CTA391854OtherOXFORD HEALTH PLAN
CT004257160Medicaid
CT004257194Medicaid
CT248108OtherMANAGED HEALTH NETWORK
CT004257201Medicaid