Healthcare Provider Details

I. General information

NPI: 1699216242
Provider Name (Legal Business Name): COREY ROOS PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LEWIS ST STE 202
GREENWICH CT
06830-5537
US

IV. Provider business mailing address

160 NICOLL ST
NEW HAVEN CT
06511-2624
US

V. Phone/Fax

Practice location:
  • Phone: 203-623-5882
  • Fax:
Mailing address:
  • Phone: 203-623-5882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003934
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: