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General NPI Number Information
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NPI Number | 1669466561
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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 | 09/07/2005
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Last Update Date | 05/04/2023
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Provider Practice Location Address
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Address Line | 263 FARMINGTON AVENUE
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City | FARMINGTON
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State | CT
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Zip | 06030-5355
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Country | US
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Telephone | 860-679-2916
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Fax | 860-679-3071
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Provider Business Mailing Address
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Address Line | 263 FARMINGTON AVENUE
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City | FARMINGTON
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State | CT
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Zip | 06030-5355
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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 FINANCIAL OFFICER
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Name | JEFFREY GEOGHEGAN
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Credential |
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Telephone | 860-679-3162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 00065
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 00065
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 00065
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State | CT
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Taxonomy #5
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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License Number | 00065
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License Number State | CT
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Taxonomy #6
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 00065
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License Number State | CT
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