Provider Demographics
NPI:1356335798
Name:KEYSTONE HOUSE INC.
Entity type:Organization
Organization Name:KEYSTONE HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:RN MPH
Authorized Official - Phone:203-956-7816
Mailing Address - Street 1:147 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-3709
Mailing Address - Country:US
Mailing Address - Phone:203-956-7816
Mailing Address - Fax:
Practice Address - Street 1:147 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-3709
Practice Address - Country:US
Practice Address - Phone:203-956-7816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0RLC0022320800000X
CT0RLC0016320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004246428Medicaid
CT004246436Medicaid