Provider Demographics
NPI:1386765089
Name:EDADVANCE
Entity type:Organization
Organization Name:EDADVANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KITCHING
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:860-567-0863
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-0909
Mailing Address - Country:US
Mailing Address - Phone:860-567-0863
Mailing Address - Fax:860-567-3381
Practice Address - Street 1:355 GOSHEN ROAD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759
Practice Address - Country:US
Practice Address - Phone:860-733-3995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT251300000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004186541Medicaid