Provider Demographics
NPI:1063437895
Name:TOWN OF BRANFORD
Entity type:Organization
Organization Name:TOWN OF BRANFORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-481-4248
Mailing Address - Street 1:342 HARBOR STREET
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405
Mailing Address - Country:US
Mailing Address - Phone:203-481-4248
Mailing Address - Fax:203-483-7727
Practice Address - Street 1:342 HARBOR STREET
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405
Practice Address - Country:US
Practice Address - Phone:203-481-4248
Practice Address - Fax:203-483-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0054351041C0700X
CT002668103TC0700X
CT0142482084P0800X
CT1942449186106H00000X
CTC014902084P0804X
CTC0149261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC-0149OtherSTATE LIC. NUMBER
CTANC1650OtherOXFORD INS. GRP NO.
CT142474OtherVALUE OPTS. B.H. ID NO.
CT004051884Medicaid
CT191065OtherM.H.N./H.M.C. GRP NO.
CT004051884Medicaid