Provider Demographics
NPI:1811379662
Name:PETER TOLISANO PSYD LLC
Entity Type:Organization
Organization Name:PETER TOLISANO PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TOLISANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-778-4942
Mailing Address - Street 1:111 DEKOVEN DR
Mailing Address - Street 2:#1201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3403
Mailing Address - Country:US
Mailing Address - Phone:860-778-4942
Mailing Address - Fax:
Practice Address - Street 1:68 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2445
Practice Address - Country:US
Practice Address - Phone:860-778-4942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-28
Last Update Date:2015-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2993251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health