Healthcare Provider Details

I. General information

NPI: 1700893807
Provider Name (Legal Business Name): CONNECTICUT RENAISSANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 FRANKLIN ST
STAMFORD CT
06901-1014
US

IV. Provider business mailing address

350 FAIRFIELD AVE SUITE 701
BRIDGEPORT CT
06604-6014
US

V. Phone/Fax

Practice location:
  • Phone: 203-602-4441
  • Fax: 203-602-7782
Mailing address:
  • Phone: 203-336-5225
  • Fax: 203-226-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberC-0266
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberSA-0188
License Number StateCT

VIII. Authorized Official

Name: JOY NICOLE PENDOLA
Title or Position: COO
Credential:
Phone: 203-336-5225