Provider Demographics
NPI:1326342858
Name:CT PSYCHOLOGICAL & ASSESSMENT CENTER LLC
Entity Type:Organization
Organization Name:CT PSYCHOLOGICAL & ASSESSMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-372-4811
Mailing Address - Street 1:1028 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2617
Mailing Address - Country:US
Mailing Address - Phone:860-372-4811
Mailing Address - Fax:860-372-4812
Practice Address - Street 1:61 WELLS RD
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-3043
Practice Address - Country:US
Practice Address - Phone:860-372-4811
Practice Address - Fax:860-372-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1997101YP2500X
CT1820103TC1900X
CT72601041C0700X
CT44801041C0700X
CT36341041C0700X
CT72791041C0700X
CT59851041C0700X
CT3809363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty