Provider Demographics
NPI:1922661149
Name:WYSOCKI, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 HORSEPLAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1621
Mailing Address - Country:US
Mailing Address - Phone:860-259-8580
Mailing Address - Fax:
Practice Address - Street 1:87 HORSEPLAIN RD
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-1621
Practice Address - Country:US
Practice Address - Phone:860-259-8580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54488327894523456214103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00378746262874568725Medicaid