Healthcare Provider Details

I. General information

NPI: 1891989026
Provider Name (Legal Business Name): HARTFORD PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WETHERSFIELD AVE
HARTFORD CT
06114-1113
US

IV. Provider business mailing address

210 WETHERSFIELD AVE
HARTFORD CT
06114-1113
US

V. Phone/Fax

Practice location:
  • Phone: 860-296-0094
  • Fax: 860-206-1184
Mailing address:
  • Phone: 860-296-0094
  • Fax: 860-206-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number103T00000X
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1041C0700X
License Number StateCT

VIII. Authorized Official

Name: DR. RAFAEL MORA DE JESUS
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 860-296-0094