Healthcare Provider Details

I. General information

NPI: 1679499164
Provider Name (Legal Business Name): ASPEN GROVE PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ROCKWELL CT
SOUTH WINDSOR CT
06074-6901
US

IV. Provider business mailing address

18 ROCKWELL CT
SOUTH WINDSOR CT
06074-6901
US

V. Phone/Fax

Practice location:
  • Phone: 860-251-9316
  • Fax: 860-261-0655
Mailing address:
  • Phone: 860-251-9316
  • Fax: 860-261-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL STORK
Title or Position: MANAGING MEMBER
Credential: PSYD
Phone: 614-634-6603