Provider Demographics
NPI:1710019963
Name:PROFESSIONAL RESOURCE GROUP PC
Entity Type:Organization
Organization Name:PROFESSIONAL RESOURCE GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANABAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-456-4604
Mailing Address - Street 1:207 STORRS RD # 174
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1638
Mailing Address - Country:US
Mailing Address - Phone:860-456-4604
Mailing Address - Fax:860-456-1738
Practice Address - Street 1:207 STORRS RD # 174
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1638
Practice Address - Country:US
Practice Address - Phone:860-456-4604
Practice Address - Fax:860-456-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103TC0700X, 106H00000X, 363LP0808X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004398047Medicaid
CT008002985Medicaid
CT004255057Medicaid
CT620000199OtherMEDICARE
CT008033020Medicaid
297211OtherMHN
C007612OtherTRICARE
CT004255007Medicaid
CT004398047Medicaid