Provider Demographics
NPI:1285862425
Name:LONGBRAKE, ERIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIN
Middle Name:
Last Name:LONGBRAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:FL 6
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:203-785-6610
Mailing Address - Fax:203-785-6414
Practice Address - Street 1:6 DEVINE ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2195
Practice Address - Country:US
Practice Address - Phone:203-287-6100
Practice Address - Fax:203-287-6101
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130052952084N0400X, 207R00000X
CT550762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL56740053Medicaid