Provider Demographics
NPI:1285610584
Name:LOWER NAUGATUCK VALLEY PARENT CHILD RESOURCE CENTER, INC.
Entity type:Organization
Organization Name:LOWER NAUGATUCK VALLEY PARENT CHILD RESOURCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-954-0543
Mailing Address - Street 1:30 ELIZABETH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1802
Mailing Address - Country:US
Mailing Address - Phone:203-954-0543
Mailing Address - Fax:203-954-0544
Practice Address - Street 1:30 ELIZABETH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1802
Practice Address - Country:US
Practice Address - Phone:203-954-0543
Practice Address - Fax:203-954-0544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0PCC-9101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty