Healthcare Provider Details

I. General information

NPI: 1710019963
Provider Name (Legal Business Name): PROFESSIONAL RESOURCE GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 STORRS RD # 174
MANSFIELD CENTER CT
06250-1638
US

IV. Provider business mailing address

207 STORRS RD # 174
MANSFIELD CENTER CT
06250-1638
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-4604
  • Fax: 860-456-1738
Mailing address:
  • Phone: 860-456-4604
  • Fax: 860-456-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateCT

VIII. Authorized Official

Name: GARY P KANABAY
Title or Position: DIRECTOR PRESIDENT
Credential: PSYD
Phone: 860-456-4604