Provider Demographics
NPI:1720130362
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:DAWN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PATSTON
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 1:1126 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4404
Practice Address - Country:US
Practice Address - Phone:203-368-9755
Practice Address - Fax:203-368-9760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0412261QM0801X
CT0350261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002559Medicaid
CT008002559Medicaid