Provider Demographics
NPI:1952932279
Name:DEJESUS, EDWIN RAUL
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:RAUL
Last Name:DEJESUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CENTERPOINT DR STE 243
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-7568
Mailing Address - Country:US
Mailing Address - Phone:855-295-3276
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:101 CENTERPOINT DR STE 243
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-7568
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician