Provider Demographics
NPI:1285878306
Name:QUINNIPIAC PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:QUINNIPIAC PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:FARNSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:203-787-9009
Mailing Address - Street 1:3074 WHITNEY AVE
Mailing Address - Street 2:BUILDING TWO
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2391
Mailing Address - Country:US
Mailing Address - Phone:203-287-9009
Mailing Address - Fax:
Practice Address - Street 1:3074 WHITNEY AVE
Practice Address - Street 2:BUILDING TWO
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2391
Practice Address - Country:US
Practice Address - Phone:203-287-9009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001605Medicare PIN