Provider Demographics
NPI:1871644369
Name:ROSSOMANDO, NINA P (PHD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:P
Last Name:ROSSOMANDO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 VAUXHALL STREET EXT
Mailing Address - Street 2:SUITE 317
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4330
Mailing Address - Country:US
Mailing Address - Phone:860-444-6159
Mailing Address - Fax:860-444-7111
Practice Address - Street 1:567 VAUXHALL STREET EXT
Practice Address - Street 2:SUITE 317
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4330
Practice Address - Country:US
Practice Address - Phone:860-444-6159
Practice Address - Fax:860-444-7111
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT645103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060000645CT03OtherANTHEM BCBS OF CT
072470OtherVALUE OPTIONS
176468OtherMANAGED HEALTH NETWORK