Basic Information
| Provider Information | |||||||||
| NPI: | 1497849624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC CHARITIES, INC. - ARCHDIOCESE OF HARTFORD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATHOLIC FAMILY SERVICES, INC. - ARCHDIOCESE OF HARTFORD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 ASYLUM AVE., | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604931841 | ||||||||
| FaxNumber: | 8605481930 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 WAKELEE AVE. | ||||||||
| Address2: | |||||||||
| City: | ANSONIA | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604931841 | ||||||||
| FaxNumber: | 8695481930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | KUKULKA | ||||||||
| AuthorizedOfficialFirstName: | MAREK | ||||||||
| AuthorizedOfficialMiddleName: | KRZYSTOF | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8607282566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 004040978 | 05 | CT | MEDICAID | 183459 | 01 | CO | HEALTHNET/MHN | OTHER | 77ABH0007CT | 01 | CT | BC/BS | OTHER |