1881727600 NPI number — DR. CLARISSE G DICANDIA PSYD

Table of content: DR. CLARISSE G DICANDIA PSYD (NPI 1881727600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881727600 NPI number — DR. CLARISSE G DICANDIA PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICANDIA
Provider First Name:
CLARISSE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881727600
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYSTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06355-0333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-442-6777
Provider Business Mailing Address Fax Number:
203-481-5291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
567 VAUXHALL ST EXT
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-442-6777
Provider Business Practice Location Address Fax Number:
203-481-5291
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  001698 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060001698CT02 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 5217064 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 168925 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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