Healthcare Provider Details

I. General information

NPI: 1750459855
Provider Name (Legal Business Name): STATE OF CONNECTICUT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 RIVER ROAD
MIDDLETOWN CT
06457-3921
US

IV. Provider business mailing address

915 RIVER ROAD
MIDDLETOWN CT
06457-3921
US

V. Phone/Fax

Practice location:
  • Phone: 860-704-4090
  • Fax: 860-704-4123
Mailing address:
  • Phone: 860-704-4090
  • Fax: 860-704-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHELLE SAROFIN
Title or Position: SUPERINTENDENT
Credential: LCSW
Phone: 860-704-4090