Healthcare Provider Details

I. General information

NPI: 1619245313
Provider Name (Legal Business Name): KRISTA DALBEC MRAZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEBRON AVE UNIT 111
GLASTONBURY CT
06033-2176
US

IV. Provider business mailing address

300 HEBRON AVE UNIT 111
GLASTONBURY CT
06033-2176
US

V. Phone/Fax

Practice location:
  • Phone: 860-633-8155
  • Fax:
Mailing address:
  • Phone: 860-633-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number002990
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: