Provider Demographics
NPI:1164570339
Name:GUITAR, LEONARD G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:G
Last Name:GUITAR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LEONARD
Other - Middle Name:GRISWOLD
Other - Last Name:GUITAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:13 PARK SIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-3429
Mailing Address - Country:US
Mailing Address - Phone:860-434-0377
Mailing Address - Fax:860-434-0434
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2373
Practice Address - Country:US
Practice Address - Phone:860-358-3923
Practice Address - Fax:860-510-0628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001434103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4118049Medicaid