Healthcare Provider Details

I. General information

NPI: 1326553983
Provider Name (Legal Business Name): MARISSA SICLEY-ROGERS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVE BLDG 5TH
HARTFORD CT
06106-3309
US

IV. Provider business mailing address

211 NELSON ST
CHICOPEE MA
01013-3543
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-7058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3715
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: