Provider Demographics
NPI:1295194546
Name:RIVER VALLEY NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:RIVER VALLEY NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-230-8851
Mailing Address - Street 1:234 GURLEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268-1416
Mailing Address - Country:US
Mailing Address - Phone:860-230-8851
Mailing Address - Fax:860-812-2317
Practice Address - Street 1:322 MAIN ST STE 2E-10
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3152
Practice Address - Country:US
Practice Address - Phone:860-230-8851
Practice Address - Fax:860-812-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002504103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty