Provider Demographics
NPI:1811132103
Name:EASTCONN
Entity type:Organization
Organization Name:EASTCONN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SERVICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-455-1590
Mailing Address - Street 1:376 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06247-1320
Mailing Address - Country:US
Mailing Address - Phone:860-455-0707
Mailing Address - Fax:860-455-8002
Practice Address - Street 1:376 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06247-1320
Practice Address - Country:US
Practice Address - Phone:860-455-0707
Practice Address - Fax:860-455-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004185866Medicaid