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General NPI Number Information
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NPI Number | 1679839229
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Entity Type | Organization
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Legal Business Name | PEDIATRIC PSYCHOLOGY OF CONNECTICUT, LLC
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Dates
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Enumeration Date | 04/09/2012
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Last Update Date | 04/09/2012
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Provider Practice Location Address
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Address Line | 413 ORANGE ST SUITE 1
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City | NEW HAVEN
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State | CT
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Zip | 06511-6424
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Country | US
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Telephone | 888-342-6002
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Fax | 347-344-6594
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Provider Business Mailing Address
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Address Line | PO BOX 4098
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City | WOODBRIDGE
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State | CT
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Zip | 06525-0298
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Country | US
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Telephone | 888-342-6002
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Fax | 347-344-6594
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Authorized Official
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Title or Position | MEMBER
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Name | DR. MARK VINCENT GRUDBERG
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Credential | PH.D.
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Telephone | 888-342-6002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3139
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License Number State | CT
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