Healthcare Provider Details

I. General information

NPI: 1740495068
Provider Name (Legal Business Name): RYAN BUZZELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 MIDDLE TPKE E
MANCHESTER CT
06040-3731
US

IV. Provider business mailing address

24 ELSIE DR
MANCHESTER CT
06042-3432
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-3888
  • Fax: 860-645-4132
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: