Provider Demographics
NPI:1699851568
Name:TICHY, EILEEN MARY (PAC RD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARY
Last Name:TICHY
Suffix:
Gender:F
Credentials:PAC RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 TALCOTT RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-5001
Mailing Address - Country:US
Mailing Address - Phone:203-204-2398
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST S
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1717
Practice Address - Country:US
Practice Address - Phone:203-785-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001042363AM0700X
CTPENDING133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered