Healthcare Provider Details

I. General information

NPI: 1659716405
Provider Name (Legal Business Name): PROJECT COURAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ELM ST
OLD SAYBROOK CT
06475-4105
US

IV. Provider business mailing address

130 ELM ST
OLD SAYBROOK CT
06475-4105
US

V. Phone/Fax

Practice location:
  • Phone: 860-388-9656
  • Fax: 954-370-6447
Mailing address:
  • Phone: 860-388-9656
  • Fax: 860-388-9463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: RYAN HOCKING
Title or Position: ASSISTANT EXECUTIVE DIRECTOR
Credential:
Phone: 860-388-9656