Provider Demographics
NPI:1053738641
Name:WAYFARING MININSTRIES INC.
Entity type:Organization
Organization Name:WAYFARING MININSTRIES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-248-2729
Mailing Address - Street 1:29 MARNE ST. REAR
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-4140
Mailing Address - Country:US
Mailing Address - Phone:203-248-2729
Mailing Address - Fax:203-248-4572
Practice Address - Street 1:295 TREADWELL ST
Practice Address - Street 2:BUILDING C
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-4140
Practice Address - Country:US
Practice Address - Phone:203-248-2729
Practice Address - Fax:203-248-4572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003563251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management