Provider Demographics
NPI:1902831548
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:SOUTHEASTERN MENTAL HEALTH AUTHORITY
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 1:401 WEST THAMES STREET
Mailing Address - Street 2:BUILDING 301
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-859-4674
Mailing Address - Fax:860-859-4790
Practice Address - Street 1:401 WEST THAMES STREET
Practice Address - Street 2:BUILDING 301
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-859-4674
Practice Address - Fax:860-859-4790
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
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004220307Medicaid
CT004120200Medicaid
CT004220307Medicaid