Provider Demographics
NPI:1427074426
Name:STATE OF CONNECTICUT
Entity type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIPIETRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-418-6923
Mailing Address - Street 1:SILVER STREET
Mailing Address - Street 2:DUTTON HOME
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-262-5224
Mailing Address - Fax:860-262-5359
Practice Address - Street 1:SILVER STREET
Practice Address - Street 2:DUTTON HOME
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-262-5224
Practice Address - Fax:860-262-5359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004120151Medicaid
CT004214946Medicaid
CT004214946Medicaid