Provider Demographics
NPI:1740297845
Name:CONNECTICUT RENAISSANCE, INC.
Entity type:Organization
Organization Name:CONNECTICUT RENAISSANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCAULIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LADC
Authorized Official - Phone:203-336-5225
Mailing Address - Street 1:350 FAIRFIELD AVE
Mailing Address - Street 2:SUITE 701
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-6014
Mailing Address - Country:US
Mailing Address - Phone:203-336-5225
Mailing Address - Fax:203-336-2851
Practice Address - Street 1:1120 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:203-367-6827
Practice Address - Fax:203-367-7576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0332261QR0405X
CT0397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004228575Medicaid
CT004228575Medicaid