Provider Demographics
NPI:1265903223
Name:FAIRFIELD COUNTY MENTAL WELLNESS COUNSELING, LLC
Entity type:Organization
Organization Name:FAIRFIELD COUNTY MENTAL WELLNESS COUNSELING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SILVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-500-6397
Mailing Address - Street 1:3241 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4850
Mailing Address - Country:US
Mailing Address - Phone:203-500-6397
Mailing Address - Fax:
Practice Address - Street 1:3241 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4850
Practice Address - Country:US
Practice Address - Phone:203-500-6397
Practice Address - Fax:203-383-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid