Healthcare Provider Details

I. General information

NPI: 1598817140
Provider Name (Legal Business Name): CONNECTICUT RENAISSANCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 W MAIN ST
WATERBURY CT
06702-1123
US

IV. Provider business mailing address

1 WATERVIEW DR STE 202
SHELTON CT
06484-4368
US

V. Phone/Fax

Practice location:
  • Phone: 203-591-8010
  • Fax: 203-591-8586
Mailing address:
  • Phone: 203-336-5225
  • Fax: 203-336-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0241
License Number StateCT

VIII. Authorized Official

Name: DAWN PATSTON
Title or Position: CHIEF OPERATING OFFICER
Credential: LMFT
Phone: 203-336-5225