Provider Demographics
NPI:1598051591
Name:KONERU, VAMSI (PHD)
Entity Type:Individual
Prefix:DR
First Name:VAMSI
Middle Name:
Last Name:KONERU
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 1:176 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4354
Mailing Address - Country:US
Mailing Address - Phone:305-321-5384
Mailing Address - Fax:
Practice Address - Street 1:176 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4354
Practice Address - Country:US
Practice Address - Phone:305-321-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical