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General NPI Number Information
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NPI Number | 1366950206
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Entity Type | Organization
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Legal Business Name | STATE OF CONNECTICUT
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Dates
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Enumeration Date | 01/12/2018
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Last Update Date | 01/12/2018
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Provider Practice Location Address
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Address Line | 70 O'BRIEN DRIVE
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City | MIDDLETOWN
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State | CT
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Zip | 06457
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Country | US
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Telephone | 860-418-6918
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 70
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City | MIDDLETOWN
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State | CT
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Zip | 06457-0070
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF FISCAL OFFICER
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Name | MR. STEPHEN DIPIETRO
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Credential |
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Telephone | 860-418-6926
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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