Provider Demographics
NPI:1245561463
Name:AVALON PSYCHOLOGICAL GROUP, P.C.
Entity Type:Organization
Organization Name:AVALON PSYCHOLOGICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRAUNSDORF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-558-1317
Mailing Address - Street 1:664 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4203
Mailing Address - Country:US
Mailing Address - Phone:860-558-1317
Mailing Address - Fax:
Practice Address - Street 1:664 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4203
Practice Address - Country:US
Practice Address - Phone:860-558-1317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1739103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty