Provider Demographics
NPI:1558479360
Name:KREISMAN, RHODA LYNNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RHODA
Middle Name:LYNNE
Last Name:KREISMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4206
Mailing Address - Country:US
Mailing Address - Phone:203-265-4036
Mailing Address - Fax:203-284-8302
Practice Address - Street 1:393 CENTER ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4206
Practice Address - Country:US
Practice Address - Phone:203-265-4036
Practice Address - Fax:203-284-8302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R90044Medicare UPIN
620000166Medicare ID - Type Unspecified