Provider Demographics
NPI:1831797174
Name:FENWICK, DEREK ALAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALAN
Last Name:FENWICK
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 1:200 RETREAT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3310
Mailing Address - Country:US
Mailing Address - Phone:860-545-7437
Mailing Address - Fax:860-972-5937
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3310
Practice Address - Country:US
Practice Address - Phone:860-545-7437
Practice Address - Fax:860-972-5937
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4009103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical