Provider Demographics
NPI:1881643799
Name:VASSILOPOULOS, CHARLES A (PH D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:VASSILOPOULOS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:89 FARMS VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3613
Mailing Address - Country:US
Mailing Address - Phone:860-529-1566
Mailing Address - Fax:860-563-2242
Practice Address - Street 1:147 UNION ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-3025
Practice Address - Country:US
Practice Address - Phone:860-875-1875
Practice Address - Fax:860-563-2242
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001727103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004115871Medicaid
CT004115871Medicaid