Provider Demographics
NPI:1184305534
Name:FLACK, DANIEL (PHD, JD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:FLACK
Suffix:
Gender:M
Credentials:PHD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 10
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-0010
Practice Address - Country:US
Practice Address - Phone:203-208-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
CT4619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic