Provider Demographics
NPI:1912660044
Name:TYNAN, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:TYNAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 PENN DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1042
Mailing Address - Country:US
Mailing Address - Phone:860-324-4407
Mailing Address - Fax:
Practice Address - Street 1:142 PENN DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1042
Practice Address - Country:US
Practice Address - Phone:860-324-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003719103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral