Provider Demographics
NPI:1124340203
Name:CONNECTICUT GERIATRIC PSYCHOLOGICAL SERVICES, PC
Entity type:Organization
Organization Name:CONNECTICUT GERIATRIC PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELLES
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:914-937-6174
Mailing Address - Street 1:112 BETSY BROWN RD
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2231
Mailing Address - Country:US
Mailing Address - Phone:914-937-6174
Mailing Address - Fax:914-937-6174
Practice Address - Street 1:112 BETSY BROWN RD
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-2231
Practice Address - Country:US
Practice Address - Phone:914-937-6174
Practice Address - Fax:914-937-6174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2657103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001849Medicare PIN