Basic Information
| Provider Information | |||||||||
| NPI: | 1013140656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODZELESKY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 GRISWOLD ST | ||||||||
| Address2: | HOSPITAL OF CENTRAL CONNECTICUT | ||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060522008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602245267 | ||||||||
| FaxNumber: | 8602245752 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 SOMERWYND LN | ||||||||
| Address2: | |||||||||
| City: | SUFFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060781229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606680512 | ||||||||
| FaxNumber: | 8606682838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2009 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.