Provider Demographics
NPI:1376655399
Name:BALTER, PATRICIA ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANNE
Last Name:BALTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANNE
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:40 FOX HILL RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1425
Mailing Address - Country:US
Mailing Address - Phone:203-787-5938
Mailing Address - Fax:203-787-9447
Practice Address - Street 1:234 CHURCH ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1804
Practice Address - Country:US
Practice Address - Phone:203-787-5938
Practice Address - Fax:203-787-9447
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000799103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060000799CT01OtherANTHEM BLUE CROSS/BLUE SH
CTOV8400OtherHEALTHNET
CT080257OtherMHN
CT049674OtherVALUE OPTIONS