=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770865883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAN SANTANDREU MIRABAL PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 JEFFERSON STREET
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-972-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 LIBERTY ST STE 102
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01103-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-200-4110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 9906
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4020
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------