MEDICARE: MARY JO PUGLISI VASQUEZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	016768	NY
2	103TC0700X	Clinical Psychologist	3188	CT

General Provider Information

NPI Number	:	1467572479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JO PUGLISI VASQUEZ PH.D.

Provider Business Mailing Address
First Line	:	2335 BLACK ROCK TPKE
Second Line	:	HALL #2
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3220
Country	:	US
Telephone Number	:	203-816-0183
Fax Number	:

Provider Business Practice Location Address
First Line	:	2335 BLACK ROCK TPKE
Second Line	:	HALL #2
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3220
Country	:	US
Telephone Number	:	203-816-0183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	05/16/2014

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