Provider Demographics
NPI:1154607208
Name:CREC RIVER STREET AUTISM PROGRAM AT COLTSVILLE
Entity type:Organization
Organization Name:CREC RIVER STREET AUTISM PROGRAM AT COLTSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PARVENSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-298-0079
Mailing Address - Street 1:111 CHARTER OAK AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1912
Mailing Address - Country:US
Mailing Address - Phone:860-298-9079
Mailing Address - Fax:860-722-9438
Practice Address - Street 1:111 CHARTER OAK AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1912
Practice Address - Country:US
Practice Address - Phone:860-298-9079
Practice Address - Fax:860-722-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1000342103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty