Provider Demographics
NPI:1629635412
Name:COURAGE TO BE LLC
Entity Type:Organization
Organization Name:COURAGE TO BE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:YANIQUE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-245-1027
Mailing Address - Street 1:78 MONTOWESE ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-3041
Mailing Address - Country:US
Mailing Address - Phone:860-245-1027
Mailing Address - Fax:
Practice Address - Street 1:34 JEROME AVE STE 116
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2463
Practice Address - Country:US
Practice Address - Phone:860-245-1027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1649638735Medicaid