Provider Demographics
NPI:1619945987
Name:SELLS, CORY BRIDWELL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:BRIDWELL
Last Name:SELLS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CORY
Other - Middle Name:RARDIN
Other - Last Name:BRIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:176 AMITY RD # 232
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2239
Mailing Address - Country:US
Mailing Address - Phone:203-232-0716
Mailing Address - Fax:
Practice Address - Street 1:176 AMITY RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2239
Practice Address - Country:US
Practice Address - Phone:203-736-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002595103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00235918Medicaid
CT11751794OtherCAQH