MEDICARE: EASTER SEALS CONNECTICUT INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	800009104CT01	OTHER	CT	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902888449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS CONNECTICUT INC.

Provider Business Mailing Address
First Line	:	120 HOLCOMB ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06112-1529
Country	:	US
Telephone Number	:	860-242-2274
Fax Number	:	860-769-6564

Provider Business Practice Location Address
First Line	:	733 SUMMER ST
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06901-1081
Country	:	US
Telephone Number	:	860-242-2274
Fax Number	:	860-769-6564

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. BARRY M SIMON
Credential	:
Telephone Number	:	860-769-3901

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	07/21/2015

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