Provider Demographics
NPI:1548558232
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:MA
Authorized Official - Phone:860-904-3444
Mailing Address - Street 1:61 WELLS RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3043
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:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001997101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008025895Medicaid