Provider Demographics
NPI:1992999767
Name:SHORELINE PEDIATRIC NEUROPSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:SHORELINE PEDIATRIC NEUROPSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEUROPSYCHOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:FRAZIER
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-388-2000
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475
Mailing Address - Country:US
Mailing Address - Phone:860-388-2000
Mailing Address - Fax:860-388-2000
Practice Address - Street 1:954 MIDDLESEX TPKE
Practice Address - Street 2:STE A2
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1302
Practice Address - Country:US
Practice Address - Phone:860-388-2000
Practice Address - Fax:860-388-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2736103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty