Healthcare Provider Details

I. General information

NPI: 1023371275
Provider Name (Legal Business Name): HOSPITAL OF SAINT RAPHAEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1294 CHAPEL ST 2ND FLOOR
NEW HAVEN CT
06511-4515
US

IV. Provider business mailing address

1294 CHAPEL ST 2ND FLOOR
NEW HAVEN CT
06511-4515
US

V. Phone/Fax

Practice location:
  • Phone: 203-784-8750
  • Fax:
Mailing address:
  • Phone: 203-784-8750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER BALLEW
Title or Position: MEDICAL DIRECTOR
Credential: D.O
Phone: 203-784-8750