Provider Demographics
NPI:1346225273
Name:GRESHAM, KAREN M (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:M
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SAYBROOK RD
Mailing Address - Street 2:BLD B
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4739
Mailing Address - Country:US
Mailing Address - Phone:860-347-3466
Mailing Address - Fax:860-343-5391
Practice Address - Street 1:770 SAYBROOK RD
Practice Address - Street 2:BLD B
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4739
Practice Address - Country:US
Practice Address - Phone:860-347-3466
Practice Address - Fax:860-343-5391
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT643106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410000643CT05OtherANTHEM BC