Healthcare Provider Details

I. General information

NPI: 1669466561
Provider Name (Legal Business Name): STATE OF CONNECTICUT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 05/04/2023
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-5355
US

IV. Provider business mailing address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-5355
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2916
  • Fax: 860-679-3071
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number00065
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number00065
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number00065
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00065
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00065
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: JEFFREY GEOGHEGAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 860-679-3162