=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407719388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE JUDSON STANNARD IV TECHNICIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2025
-----------------------------------------------------
Last Update Date | 12/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 MAIN ST STE G
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06118-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-754-0398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 BUCKLAND HILLS DR APT 14112
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-8741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-830-2579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------