Provider Demographics
NPI:1538582739
Name:EASTERN SERVICES & CAMP SIMON LLC
Entity type:Organization
Organization Name:EASTERN SERVICES & CAMP SIMON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIMVONGSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-254-5127
Mailing Address - Street 1:115 BRIDGE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9547
Mailing Address - Country:US
Mailing Address - Phone:860-254-5127
Mailing Address - Fax:860-254-5254
Practice Address - Street 1:82 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-2325
Practice Address - Country:US
Practice Address - Phone:860-254-5127
Practice Address - Fax:860-310-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT002227101YP2500X
CT001470101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty