Provider Demographics
NPI:1134230170
Name:LAUTENBACH, RICHARD ERNEST (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ERNEST
Last Name:LAUTENBACH
Suffix:
Gender:M
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:P.O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVENUE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT.
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3310
Practice Address - Country:US
Practice Address - Phone:860-545-7345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008018590Medicaid
CT008018590Medicaid