Healthcare Provider Details

I. General information

NPI: 1497812457
Provider Name (Legal Business Name): LISA GAUTHIER MICELI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BAYONET ST STE 304
NEW LONDON CT
06320-2600
US

IV. Provider business mailing address

100 GLENWOOD AVE
NEW LONDON CT
06320-4350
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-7505
  • Fax: 860-444-8895
Mailing address:
  • Phone: 860-444-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number002284
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: