Provider Demographics
NPI:1568528859
Name:FIELD, CHARLES LAWRENCE (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:FIELD
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 1:469 BUCKLAND RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3737
Mailing Address - Country:US
Mailing Address - Phone:860-644-6610
Mailing Address - Fax:860-648-9232
Practice Address - Street 1:469 BUCKLAND RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-644-6610
Practice Address - Fax:860-648-9232
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001574103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist