Provider Demographics
NPI:1770132821
Name:ZALZALA, AIEYAT BASIM (PHD)
Entity type:Individual
Prefix:
First Name:AIEYAT
Middle Name:BASIM
Last Name:ZALZALA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RETREAT AVENUE
Mailing Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3309
Mailing Address - Country:US
Mailing Address - Phone:860-696-0020
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3309
Practice Address - Country:US
Practice Address - Phone:860-696-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3856103TC1900X
CT003856103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling