Healthcare Provider Details

I. General information

NPI: 1912234311
Provider Name (Legal Business Name): KEITH HAWKINS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 PARK ST
NEW HAVEN CT
06519-1109
US

IV. Provider business mailing address

34 PARK ST
NEW HAVEN CT
06519-1109
US

V. Phone/Fax

Practice location:
  • Phone: 203-974-7831
  • Fax: 203-974-7881
Mailing address:
  • Phone: 203-974-7831
  • Fax: 203-974-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1536
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: