Provider Demographics
NPI:1164521753
Name:KANABAY, GARY PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:PAUL
Last Name:KANABAY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 STORRS RD # 174
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1638
Mailing Address - Country:US
Mailing Address - Phone:860-456-4604
Mailing Address - Fax:860-456-1738
Practice Address - Street 1:207 STORRS RD # 174
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1638
Practice Address - Country:US
Practice Address - Phone:860-456-4604
Practice Address - Fax:860-456-1738
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004070595Medicaid
107944OtherVALUE OPTIONS
2448873OtherAETNA
C007612OtherTRICARE
CT060001188CT01OtherANTHEM
080329OtherMHN
CT004070595Medicaid