Basic Information
| Provider Information | |||||||||
| NPI: | 1942676523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMEN AND CHILDRENS PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 BEACON ST | ||||||||
| Address2: | WOMEN AND CHILDRENS PROGRAM | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035743311 | ||||||||
| FaxNumber: | 2035743315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | STECK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2035749000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLMORE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.