{
"Npi": {
"NPI": "1669617973",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CONNECTICUT RENAISSANCE, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1 WATERVIEW DR STE 202",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SHELTON",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06484-4368",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "203-336-5225",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "70 CENTRAL AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WATERBURY",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06702-1207",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "203-346-1931",
"PracticeLocationAddressFaxNumber": "203-346-1935",
"EnumerationDate": "12/16/2008",
"LastUpdateDate": "06/30/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PATSTON",
"AuthorizedOfficialFirstName": "DAWN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CHIEF OPERATING OFFICER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LMFT",
"AuthorizedOfficialTelephoneNumber": "203-336-5225",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": "0449",
"LicenseNumberStateCode": "CT",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "324500000X",
"TaxonomyName": "Substance Abuse Rehabilitation Facility",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}