Provider Demographics
NPI:1871101733
Name:NEW CANAAN GROUP HOME INC
Entity type:Organization
Organization Name:NEW CANAAN GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANZHAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-846-9581
Mailing Address - Street 1:162 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5728
Mailing Address - Country:US
Mailing Address - Phone:203-846-9581
Mailing Address - Fax:203-847-0545
Practice Address - Street 1:162 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5728
Practice Address - Country:US
Practice Address - Phone:203-846-9581
Practice Address - Fax:203-847-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002900OtherDDS LICENSE NUMBER