Provider Demographics
NPI:1720178049
Name:PENTA, CHRISTOPHER RALPH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:RALPH
Last Name:PENTA
Suffix:
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 1:41 MECHANIC STREER
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095
Mailing Address - Country:US
Mailing Address - Phone:860-285-8270
Mailing Address - Fax:860-688-0004
Practice Address - Street 1:41 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2545
Practice Address - Country:US
Practice Address - Phone:860-285-8270
Practice Address - Fax:860-722-3162
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2378103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
680001479Medicare ID - Type Unspecified