Healthcare Provider Details

I. General information

NPI: 1740737139
Provider Name (Legal Business Name): MICHAEL REISS M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

10 COLUMBUS BLVD FL 4
HARTFORD CT
06106-1976
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9520
  • Fax:
Mailing address:
  • Phone: 508-791-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3783
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: