Provider Demographics
NPI:1699952853
Name:GLEESON, EVELYN M (MB BCH BAO)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:M
Last Name:GLEESON
Suffix:
Gender:F
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:99 EAST RIVER DR
Mailing Address - Street 2:5TH FL
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-522-9711
Mailing Address - Fax:860-493-1885
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:4304
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-522-3711
Practice Address - Fax:860-493-1885
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT0470782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
D400003719Medicare PIN