Provider Demographics
NPI:1992074413
Name:MIDWESTERN CONNECTICUT COUNCIL ON ALCOHOLISM, INC.
Entity type:Organization
Organization Name:MIDWESTERN CONNECTICUT COUNCIL ON ALCOHOLISM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V.P OF BEHAVIORAL HEALTHCARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAPTARDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-792-4515
Mailing Address - Street 1:38 OLD RIDGEBURY RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5128
Mailing Address - Country:US
Mailing Address - Phone:203-792-4515
Mailing Address - Fax:203-748-2604
Practice Address - Street 1:62 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3547
Practice Address - Country:US
Practice Address - Phone:860-355-7312
Practice Address - Fax:860-354-7023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTSA-0215251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008031626Medicaid