Provider Demographics
NPI:1649321696
Name:CONNECTICUT RENAISSANCE, INC
Entity type:Organization
Organization Name:CONNECTICUT RENAISSANCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PENDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-336-5225
Mailing Address - Street 1:1 WATERVIEW DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4368
Mailing Address - Country:US
Mailing Address - Phone:203-336-5225
Mailing Address - Fax:203-336-2851
Practice Address - Street 1:31 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1727
Practice Address - Country:US
Practice Address - Phone:203-753-2341
Practice Address - Fax:203-755-6902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONNECTICUT RENAISSANCE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTSA-0056324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02349Medicare ID - Type Unspecified