Provider Demographics
NPI:1750459855
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:ALBERT J. SOLNIT CHILDREN'S CENTER-SOUTH CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAROFIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-704-4090
Mailing Address - Street 1:915 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3921
Mailing Address - Country:US
Mailing Address - Phone:860-704-4090
Mailing Address - Fax:860-704-4123
Practice Address - Street 1:915 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3921
Practice Address - Country:US
Practice Address - Phone:860-704-4090
Practice Address - Fax:860-704-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004042214Medicaid