Healthcare Provider Details

I. General information

NPI: 1508121989
Provider Name (Legal Business Name): ROBERT HENRY PIETRZAK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE 151E
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

118 LYMAN ST
NEW BRITAIN CT
06053-3778
US

V. Phone/Fax

Practice location:
  • Phone: 860-638-7467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number003183
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003183
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: