Provider Demographics
NPI:1043348204
Name:ST. VINCENT DEPAUL MISSION OF WATERBURY, INC.
Entity Type:Organization
Organization Name:ST. VINCENT DEPAUL MISSION OF WATERBURY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:IADAROLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-754-0000
Mailing Address - Street 1:173 MARK LN
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-2474
Mailing Address - Country:US
Mailing Address - Phone:203-757-0567
Mailing Address - Fax:203-757-0568
Practice Address - Street 1:86 MIDLAND RD # 88
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3414
Practice Address - Country:US
Practice Address - Phone:203-753-3342
Practice Address - Fax:203-753-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTRCL-0029320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004246519Medicaid