Basic Information
| Provider Information | |||||||||
| NPI: | 1003255274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOSKA | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069025113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039690802 | ||||||||
| FaxNumber: | 2033169024 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069025113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039690802 | ||||||||
| FaxNumber: | 2033169024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2013 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301015521 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 3515 | CT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.