Provider Demographics
NPI:1639177926
Name:EASTER SEALS CAPITAL REGION & EASTERN CONNECTICUT, INC.
Entity Type:Organization
Organization Name:EASTER SEALS CAPITAL REGION & EASTERN CONNECTICUT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-714-9501
Mailing Address - Street 1:100 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-4252
Mailing Address - Country:US
Mailing Address - Phone:860-714-9500
Mailing Address - Fax:860-714-8979
Practice Address - Street 1:100 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-4252
Practice Address - Country:US
Practice Address - Phone:860-714-9500
Practice Address - Fax:860-714-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT074502261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004039632Medicaid
CT004039632Medicaid
CT074502Medicare Oscar/Certification