Provider Demographics
NPI: | 1467552067 |
---|---|
Name: | STERN, MICHAEL L (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MICHAEL |
Middle Name: | L |
Last Name: | STERN |
Suffix: | |
Gender: | M |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 60 OLD NEW MILFORD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BROOKFIELD |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06804-2430 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-740-2900 |
Mailing Address - Fax: | 203-702-5096 |
Practice Address - Street 1: | 60 OLD NEW MILFORD RD |
Practice Address - Street 2: | |
Practice Address - City: | BROOKFIELD |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06804-2430 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-740-2900 |
Practice Address - Fax: | 203-702-5096 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-09-23 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 775 | 103TA0400X, 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
Not Answered | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 060000775CT01 | Other | ANTHEM |