Provider Demographics
NPI:1356568851
Name:TOLISANO, PETER PAUL JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:PAUL
Last Name:TOLISANO
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DEKOVEN DR APT 1202
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3465
Mailing Address - Country:US
Mailing Address - Phone:860-778-4942
Mailing Address - Fax:
Practice Address - Street 1:68 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2445
Practice Address - Country:US
Practice Address - Phone:860-778-4942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0300010OtherMBHP
MA1300881Medicaid