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NPI Code Detail

MEDICARE: AVON SIMSBURY PSYCHOTHERAPY, LLC

MEDICARE: AVON SIMSBURY PSYCHOTHERAPY, LLC
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
1103T00000XPsychologist1811CT

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1680001804OTHERCTMEDICARE IDENTIFICATION NUMBER

General Provider Information

NPI Number : 1558787176
Entity Type Code : Organization
Provider Name (Legal Business Name) : AVON SIMSBURY PSYCHOTHERAPY, LLC
Provider Business Mailing Address
First Line : 111 SIMSBURY RD
Second Line :
City : AVON
State : CT
Zip : 06001-3763
Country : US
Telephone Number : 860-989-7687
Fax Number :
Provider Business Practice Location Address
First Line : 111 SIMSBURY RD
Second Line :
City : AVON
State : CT
Zip : 06001-3763
Country : US
Telephone Number : 860-989-7687
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DR. SARAH J GAMBLE
Credential : PH.D.
Telephone Number : 860-989-7687
Provider Enumeration Date : 03/06/2014
Last Update Date : 03/06/2014

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