Provider Demographics
NPI:1932466547
Name:DANIEL R BROCKETT PHD LLC
Entity Type:Organization
Organization Name:DANIEL R BROCKETT PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:203-264-3050
Mailing Address - Street 1:2 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 206D
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2288
Mailing Address - Country:US
Mailing Address - Phone:203-264-3050
Mailing Address - Fax:203-264-2426
Practice Address - Street 1:2 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 206D
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2288
Practice Address - Country:US
Practice Address - Phone:203-264-3050
Practice Address - Fax:203-264-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001851103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty