Healthcare Provider Details

I. General information

NPI: 1629635412
Provider Name (Legal Business Name): COURAGE TO BE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 JEROME AVE STE 116
BLOOMFIELD CT
06002-2463
US

IV. Provider business mailing address

78 MONTOWESE ST
HARTFORD CT
06114-3041
US

V. Phone/Fax

Practice location:
  • Phone: 860-245-1027
  • Fax:
Mailing address:
  • Phone: 860-245-1027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1649638735
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: YANIQUE J GRANT
Title or Position: CLINICAL SOCIAL WORKER
Credential:
Phone: 860-245-1027