Healthcare Provider Details

I. General information

NPI: 1336400498
Provider Name (Legal Business Name): KRISTEN M. WROCKLAGE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN M. HARRIS PH.D.

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W JOHNSON AVE STE 104
CHESHIRE CT
06410-4506
US

IV. Provider business mailing address

609 W JOHNSON AVE STE 104
CHESHIRE CT
06410-4506
US

V. Phone/Fax

Practice location:
  • Phone: 203-272-6007
  • Fax: 203-272-8895
Mailing address:
  • Phone: 203-272-6007
  • Fax: 203-272-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number003174
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: