Provider Demographics
NPI:1386077972
Name:KOMNINOS, THALIA (PHD)
Entity type:Individual
Prefix:DR
First Name:THALIA
Middle Name:
Last Name:KOMNINOS
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 1:78 TRIANGLE ST., I-4
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-448-3194
Mailing Address - Fax:
Practice Address - Street 1:78 TRIANGLE ST., I-4
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-448-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003213103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical