Provider Demographics
NPI:1962278119
Name:THE SUPPORTED LIVING GROUP, LLC
Entity type:Organization
Organization Name:THE SUPPORTED LIVING GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, COO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-933-6284
Mailing Address - Street 1:113 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-3022
Mailing Address - Country:US
Mailing Address - Phone:860-933-6284
Mailing Address - Fax:860-412-9232
Practice Address - Street 1:113 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-3022
Practice Address - Country:US
Practice Address - Phone:860-933-6284
Practice Address - Fax:860-412-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008099131Medicaid
CT008101318Medicaid
CT008120112Medicaid
CT008065199Medicaid