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109 Legion Ave New Haven CT 06519-5506 | |
| (203) 562-2264 | |
| (203) 789-1335 |
| Full Name | |
|---|---|
| Speciality | Community Based Residential Treatment Facility, Mental Illness |
| Location | 109 Legion Ave, New Haven, Connecticut |
| Authorized Official Name and Position | James G Farrales (PRESIDENT, CEO) |
| Authorized Official Contact | 2035622264 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
109 Legion Ave New Haven CT 06519-5506 Ph: (203) 562-2264 | 109 Legion Ave New Haven CT 06519-5506 Ph: (203) 562-2264 |
| NPI Number | 1922132083 |
|---|---|
| Provider Enumeration Date | 03/14/2007 |
| Last Update Date | 10/01/2024 |
| Certification Date | 10/01/2024 |
| Medicare PECOS PAC ID | 8921398876 |
|---|---|
| Medicare Enrollment ID | O20160606000184 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922132083 | NPI | - | NPPES |
| Provider Name | Ellyn Shander |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1134278500 PECOS PAC ID: 6608058243 Enrollment ID: I20110303000398 |
| Provider Name | Wanda D Jofre |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1356593321 PECOS PAC ID: 7113163445 Enrollment ID: I20130711000080 |
| Provider Name | Allison K Underwood |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184051526 PECOS PAC ID: 2163739905 Enrollment ID: I20150911000507 |
| Provider Name | John D Cahill |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1467690271 PECOS PAC ID: 2668774936 Enrollment ID: I20160104000494 |
| Provider Name | Dominique G Decilla |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1891160206 PECOS PAC ID: 6507145075 Enrollment ID: I20161128001917 |
| Provider Name | Cynthia N Benoit |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1346614542 PECOS PAC ID: 6305120296 Enrollment ID: I20170221000196 |
| Provider Name | Louis Damora |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1477079499 PECOS PAC ID: 9133495294 Enrollment ID: I20171018000991 |
| Provider Name | Susan J. Kelly |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1356773097 PECOS PAC ID: 3678966207 Enrollment ID: I20220203000916 |
| Provider Name | Kristy A Sinkovich |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1225598824 PECOS PAC ID: 1052706918 Enrollment ID: I20220311002133 |
| Provider Name | Rachel Jean Maguire |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285305698 PECOS PAC ID: 3577959865 Enrollment ID: I20220414000428 |
| Provider Name | Sean Keiran |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1578103222 PECOS PAC ID: 8921478926 Enrollment ID: I20230109002585 |
| Provider Name | Yichu Xu |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1164137089 PECOS PAC ID: 8325498942 Enrollment ID: I20231222001400 |
| Provider Name | Alyson Claire Spencer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1033996764 PECOS PAC ID: 6608312350 Enrollment ID: I20240718002281 |
| Provider Name | Megan Hull |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598594699 PECOS PAC ID: 3577004480 Enrollment ID: I20240919000024 |
| Provider Name | Hillary Margolis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316776412 PECOS PAC ID: 1850832775 Enrollment ID: I20240919000325 |
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