Healthcare Provider Details

I. General information

NPI: 1689079774
Provider Name (Legal Business Name): CONNECTICUT PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FOREST PARK DRIVE
FARMINGTON CT
06032-1443
US

IV. Provider business mailing address

5 FLORENCE WAY
FARMINGTON CT
06032-3443
US

V. Phone/Fax

Practice location:
  • Phone: 860-235-3395
  • Fax: 888-504-2375
Mailing address:
  • Phone: 860-235-3395
  • Fax: 888-504-2375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number003346
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003346
License Number StateCT

VIII. Authorized Official

Name: DR. CHRISTINE L. GILLIES
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 860-235-3395