Basic Information
| Provider Information | |||||||||
| NPI: | 1285852624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED COMMUNITY AND FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTER FOR WORK AND FAMILIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 47 TOWN ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608927042 | ||||||||
| FaxNumber: | 8608927043 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063404907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608927042 | ||||||||
| FaxNumber: | 8608927043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 02/21/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMART | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8608224153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | C-0280 | CT | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 004218196 | 05 | CT | MEDICAID |