Basic Information
| Provider Information | |||||||||
| NPI: | 1982956181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COGDELL | ||||||||
| FirstName: | BRITTANNI | ||||||||
| MiddleName: | KORYN | ||||||||
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| Credential: | LPC,MA,BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 GRIGGS ST | ||||||||
| Address2: | THERAPEUTIC SHELTER | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067043110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035743311 | ||||||||
| FaxNumber: | 2035743315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2012 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2716 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CT | MEDICAID | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | PENDING | 01 | CAQH | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | PENDING | 01 | CT | OPTUM BEHAVIORAL HEALTH | OTHER |