Provider Demographics
NPI:1881079820
Name:FUNDAMENTAL FAMILY THERAPY, LLC
Entity type:Organization
Organization Name:FUNDAMENTAL FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-206-2784
Mailing Address - Street 1:PO BOX 11406
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06703-0406
Mailing Address - Country:US
Mailing Address - Phone:203-206-2784
Mailing Address - Fax:
Practice Address - Street 1:246 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2641
Practice Address - Country:US
Practice Address - Phone:203-206-2784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty