Provider Demographics
NPI:1841684164
Name:JEREMY EDWARD DRISCOLL
Entity type:Organization
Organization Name:JEREMY EDWARD DRISCOLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-309-7034
Mailing Address - Street 1:150 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-4262
Mailing Address - Country:US
Mailing Address - Phone:860-309-7034
Mailing Address - Fax:
Practice Address - Street 1:150 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4262
Practice Address - Country:US
Practice Address - Phone:860-309-7034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000209261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)