Healthcare Provider Details

I. General information

NPI: 1831797174
Provider Name (Legal Business Name): DEREK ALAN FENWICK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVE
HARTFORD CT
06106-3310
US

IV. Provider business mailing address

200 RETREAT AVE
HARTFORD CT
06106-3310
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-7437
  • Fax: 860-972-5937
Mailing address:
  • Phone: 860-545-7437
  • Fax: 860-972-5937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4009
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: