Provider Demographics
NPI:1215047147
Name:RADIN, LAURA (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RADIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CEDAR MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-1154
Mailing Address - Country:US
Mailing Address - Phone:860-873-2202
Mailing Address - Fax:
Practice Address - Street 1:300 HEBRON AVE STE 107
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-543-1098
Practice Address - Fax:860-430-1093
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical