Provider Demographics
NPI:1306627708
Name:CONNECTICUT PEDIATRIC NEUROPSYCHOLOGY ASSOCIATES
Entity type:Organization
Organization Name:CONNECTICUT PEDIATRIC NEUROPSYCHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ISENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-633-8155
Mailing Address - Street 1:300 HEBRON AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2176
Mailing Address - Country:US
Mailing Address - Phone:860-633-8155
Mailing Address - Fax:860-633-8176
Practice Address - Street 1:300 HEBRON AVE STE 111
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:860-633-8155
Practice Address - Fax:860-633-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty