Healthcare Provider Details

I. General information

NPI: 1467417113
Provider Name (Legal Business Name): LIANE A HENNESSEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVENUE DONNELLY BUILDING INSTITUTE OF LIVING
HARTFORD CT
06106
US

IV. Provider business mailing address

PO BOX 1086 HARTFORD MEDICAL GROUP
WILBRAHAM MA
01095-1086
US

V. Phone/Fax

Practice location:
  • Phone: 860-524-7224
  • Fax: 860-524-7482
Mailing address:
  • Phone: 508-595-0531
  • Fax: 508-829-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number000147
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: