Provider Demographics
NPI:1568473098
Name:WHITTALL, ERIC (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WHITTALL
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 1:25 WATER ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2861
Mailing Address - Country:US
Mailing Address - Phone:203-458-0661
Mailing Address - Fax:203-458-6068
Practice Address - Street 1:25 WATER ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2861
Practice Address - Country:US
Practice Address - Phone:203-458-0661
Practice Address - Fax:203-458-6068
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004165363Medicaid
CT680001710Medicare PIN