Healthcare Provider Details

I. General information

NPI: 1730656844
Provider Name (Legal Business Name): NOVA NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WASHINGTON AVE LOWR LEVEL
NORTH HAVEN CT
06473-1723
US

IV. Provider business mailing address

110 WASHINGTON AVE LOWR LEVEL
NORTH HAVEN CT
06473-1723
US

V. Phone/Fax

Practice location:
  • Phone: 203-479-0554
  • Fax: 833-411-6631
Mailing address:
  • Phone: 203-479-0554
  • Fax: 833-411-6631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN WROCKLAGE
Title or Position: OWNER
Credential: PHD
Phone: 203-479-0554