Healthcare Provider Details

I. General information

NPI: 1972588895
Provider Name (Legal Business Name): POST TRAUMATIC STRESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 EDWARDS ST
NEW HAVEN CT
06511-7313
US

IV. Provider business mailing address

19 EDWARDS ST
NEW HAVEN CT
06511-7313
US

V. Phone/Fax

Practice location:
  • Phone: 203-624-2146
  • Fax: 203-624-2791
Mailing address:
  • Phone: 203-624-2146
  • Fax: 203-624-2791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0892
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number032090
License Number StateCT
# 3
Primary TaxonomyY
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 Number001420
License Number StateCT

VIII. Authorized Official

Name: DR. HADAR LUBIN
Title or Position: CO-DIRECTOR
Credential: MD
Phone: 203-624-2146