Healthcare Provider Details

I. General information

NPI: 1295194546
Provider Name (Legal Business Name): RIVER VALLEY NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 MAIN ST STE 2E-10
WILLIMANTIC CT
06226-3152
US

IV. Provider business mailing address

234 GURLEYVILLE RD
STORRS CT
06268-1416
US

V. Phone/Fax

Practice location:
  • Phone: 860-230-8851
  • Fax: 860-812-2317
Mailing address:
  • Phone: 860-230-8851
  • Fax: 860-812-2317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0002504
License Number StateCT

VIII. Authorized Official

Name: SARAH E BULLARD
Title or Position: PHD
Credential:
Phone: 860-230-8851