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General NPI Number Information
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NPI Number | 1245561463
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Entity Type | Organization
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Legal Business Name | AVALON PSYCHOLOGICAL GROUP, P.C.
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Dates
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Enumeration Date | 01/28/2010
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Last Update Date | 01/07/2016
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Provider Practice Location Address
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Address Line | 664 PROSPECT AVE
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City | HARTFORD
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State | CT
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Zip | 06105-4203
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Country | US
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Telephone | 860-558-1317
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Fax |
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Provider Business Mailing Address
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Address Line | 664 PROSPECT AVE
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City | HARTFORD
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State | CT
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Zip | 06105-4203
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Country | US
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Telephone | 860-558-1317
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK S. BRAUNSDORF
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Credential | PHD
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Telephone | 860-558-1317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 1739
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License Number State | CT
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