Provider Demographics
NPI:1558787176
Name:AVON SIMSBURY PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:AVON SIMSBURY PSYCHOTHERAPY, LLC
Other - Org Name:SIMSBURY PSYCHOTHERAPY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-989-7687
Mailing Address - Street 1:111 SIMSBURY RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3763
Mailing Address - Country:US
Mailing Address - Phone:860-989-7687
Mailing Address - Fax:
Practice Address - Street 1:111 SIMSBURY RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3763
Practice Address - Country:US
Practice Address - Phone:860-989-7687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1811103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001804OtherMEDICARE IDENTIFICATION NUMBER