Provider Demographics
NPI:1235737735
Name:SOUTHBURY ADOLESCENT AND YOUNG ADULT COUNSELING CENTER LLC
Entity type:Organization
Organization Name:SOUTHBURY ADOLESCENT AND YOUNG ADULT COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:518-610-4528
Mailing Address - Street 1:127 WATERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1502
Mailing Address - Country:US
Mailing Address - Phone:518-610-4528
Mailing Address - Fax:
Practice Address - Street 1:519 HERITAGE RD STE 2A5
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-6694
Practice Address - Country:US
Practice Address - Phone:518-610-4528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty