Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 261QM2800X | Clinic/Center | Methadone | SA-0101 | CONNECTICUT | Yes |
| 2 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | SA-0101 | CONNECTICUT | No |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 001302497 | OTHER | CONNECTICUT | SHI MEDICAID |
| 2 | 001423136 | OTHER | CONNECTICUT | TETRAULT MEDICAID |
| 3 | 008038019 | OTHER | CONNECTICUT | MEDICAID ONOFRIO |
| 4 | 008038047 | OTHER | CONNECTICUT | DIMEOLA MEDICAID |
| 5 | D400083844 | MEDICARE PIN | CONNECTICUT | |
| 6 | 110004627 | MEDICARE PIN | CONNECTICUT | |
| 7 | D400357718 | MEDICARE PIN | CONNECTICUT | |
| 8 | D400356784 | MEDICARE PIN | CONNECTICUT | |
| 9 | 001218107 | OTHER | CONNECTICUT | SCHOTTENFELD MEDICAID |
| 10 | 004235083 | OTHER | CONNECTICUT | YOUNG MEDICAID |
| 11 | 008043611 | OTHER | CONNECTICUT | ROSS MEDICAID |
| 12 | D400360105 | MEDICARE PIN | CONNECTICUT | |
| 13 | 008061077 | OTHER | CONNECTICUT | MEDICAID VOLLONO |
| 14 | 008053091 | OTHER | CONNECTICUT | BUTNER MEDICAID |
| 15 | 500000315 | OTHER | CONNECTICUT | ORC/MEDICAID/SA |
| 16 | 008037391 | OTHER | CONNECTICUT | SHACKELL MEDICAID |
| 17 | 008038049 | OTHER | CONNECTICUT | PETHO MEDICAID |
| 18 | D400076510 | MEDICARE PIN | CONNECTICUT | |
| 19 | D400172220 | MEDICARE PIN | CONNECTICUT | |
| 20 | 008064634 | OTHER | CONNECTICUT | GARERI MEDICAID |
| 21 | 004082286 | OTHER | CONNECTICUT | ORC/MEDICAID/MMT |
| 22 | 008038019 | OTHER | CONNECTICUT | MEDICAID ONOFRIO |
| 23 | D400318773 | MEDICARE PIN | CONNECTICUT | |
| 24 | 008053715 | OTHER | CONNECTICUT | NUNLEY MEDICAID |
| 25 | 008050283 | OTHER | CONNECTICUT | HAYNES MEDICAID |
| 26 | 001340132 | OTHER | CONNECTICUT | SAVAGE MEDICAID |
| 27 | 008066551 | OTHER | CONNECTICUT | DEOLIVEIRA MEDICAID |
| 28 | D40076510 | MEDICARE PIN | CONNECTICUT | |
| 29 | 008066315 | OTHER | CONNECTICUT | COLON RIVERA MEDICAID |
| 30 | D400081097 | MEDICARE PIN | CONNECTICUT | |
| 31 | 008058217 | OTHER | CONNECTICUT | SEARS MEDICAID |
| 32 | 008003745 | OTHER | CONNECTICUT | DESROSIERS MEDICAID |
