Provider Demographics
NPI:1811315757
Name:COMMUNITY RENEWAL TEAM, INC.
Entity type:Organization
Organization Name:COMMUNITY RENEWAL TEAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN I
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:BRACAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:860-951-8770
Mailing Address - Street 1:1921 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2118
Mailing Address - Country:US
Mailing Address - Phone:860-951-8770
Mailing Address - Fax:860-233-2796
Practice Address - Street 1:1921 PARK ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2118
Practice Address - Country:US
Practice Address - Phone:860-951-8770
Practice Address - Fax:860-233-2796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY RENEWAL TEAM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1841301876302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001464Medicaid