Provider Demographics
| NPI: | 1801834890 |
|---|---|
| Name: | SAINT FRANCIS BEHAVIORAL HEALTH GROUP, P.C. |
| Entity Type: | Organization |
| Organization Name: | SAINT FRANCIS BEHAVIORAL HEALTH GROUP, P.C. |
| Other - Org Name: | PATH OUTPATIENT SERVICES |
| Other - Org Type: | Former Legal Business Name |
| Authorized Official - Title/Position: | BUSINESS MANAGER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | LAURA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | KIDA |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 860-714-9333 |
| Mailing Address - Street 1: | 675 TOWER AVE |
| Mailing Address - Street 2: | SUITE 301 |
| Mailing Address - City: | HARTFORD |
| Mailing Address - State: | CT |
| Mailing Address - Zip Code: | 06112-1273 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 860-714-2750 |
| Mailing Address - Fax: | 860-714-8591 |
| Practice Address - Street 1: | 675 TOWER AVENUE |
| Practice Address - Street 2: | SUITE 301 |
| Practice Address - City: | HARTFORD |
| Practice Address - State: | CT |
| Practice Address - Zip Code: | 06112-1260 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 860-714-2750 |
| Practice Address - Fax: | 860-714-8591 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-03 |
| Last Update Date: | 2014-01-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YA0400X, 1041C0700X, 106H00000X, 2084P0800X, 261QM0801X, 363LP0808X, 364SP0808X | ||
| CT | 101YP2500X, 103TC0700X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
| No | 364SP0808X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CT | 004197788 | Medicaid | |
| CT | 004255966 | Medicaid | |
| CT | 004256013 | Medicaid | |
| CT | 50PATHPCICT01 | Other | ANTHEM BC/BS GROUP # |
| CT | 004245909 | Medicaid | |
| CT | 004255891 | Medicaid | |
| CT | 004210069 | Medicaid | |
| CT | 004210481 | Medicaid | |
| CT | 004255891 | Medicaid |
