Provider First Line Business Practice Location Address: 
950 CAMPBELL AVE
    Provider Second Line Business Practice Location Address: 
PSYCHIATRY SVC 116A, VA CONNECTICUT HEALTHCARE SYSTEM
    Provider Business Practice Location Address City Name: 
WEST-HAVEN
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06516
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
203-932-5711
    Provider Business Practice Location Address Fax Number: 
203-937-4860
    Provider Enumeration Date: 
10/24/2006