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General NPI Number Information
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NPI Number | 1710019963
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL RESOURCE GROUP PC
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 05/01/2014
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Provider Practice Location Address
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Address Line | 207 STORRS RD # 174
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City | MANSFIELD CENTER
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State | CT
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Zip | 06250-1638
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Country | US
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Telephone | 860-456-4604
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Fax | 860-456-1738
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Provider Business Mailing Address
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Address Line | 207 STORRS RD # 174
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City | MANSFIELD CENTER
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State | CT
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Zip | 06250-1638
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Country | US
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Telephone | 860-456-4604
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Fax | 860-456-1738
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Authorized Official
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Title or Position | DIRECTOR PRESIDENT
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Name | GARY P KANABAY
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Credential | PSYD
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Telephone | 860-456-4604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State | CT
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