Provider Demographics
NPI:1174607253
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:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
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 1:38 RIDGEBURY RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5128
Practice Address - Country:US
Practice Address - Phone:203-792-4515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTSA-0215324500000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)