Basic Information
Provider Information | |||||||||
NPI: | 1164054698 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERICAN CENTER FOR COGNITIVE BEHAVIORAL TRAINING AND TREATMENT,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 AUSTIN DR | ||||||||
Address2: |   | ||||||||
City: | TOLLAND | ||||||||
State: | CT | ||||||||
PostalCode: | 060842423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605584694 | ||||||||
FaxNumber: | 8604309754 | ||||||||
Practice Location | |||||||||
Address1: | 351 PITKIN ST FL 17 | ||||||||
Address2: |   | ||||||||
City: | EAST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061086221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8604305515 | ||||||||
FaxNumber: | 8604309754 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2020 | ||||||||
LastUpdateDate: | 02/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CORDIER | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF CLINICAL PROG | ||||||||
AuthorizedOfficialTelephone: | 8604305515 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | SR. | ||||||||
AuthorizedOfficialCredential: | MALPC | ||||||||
NPICertificationDate: | 02/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 101YP2500X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.