Provider Demographics
NPI:1720013360
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:SOUTHWEST CONNECTICUT MENTAL HEALTH SYSTEM
Other - Org Type:Doing Business As
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 1:1635 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610
Mailing Address - Country:US
Mailing Address - Phone:203-551-7660
Mailing Address - Fax:203-551-7481
Practice Address - Street 1:1635 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610
Practice Address - Country:US
Practice Address - Phone:203-551-7660
Practice Address - Fax:203-551-7481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025607Medicaid
CT004122925Medicaid
CT004075669Medicaid
CT004075651Medicaid
CT004120060Medicaid
CT004025607Medicaid
CTC01001Medicare ID - Type UnspecifiedFIRST COAST