Basic Information
| Provider Information | |||||||||
| NPI: | 1568705978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARUCA-SULLIVAN | ||||||||
| FirstName: | PHELAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARUCA | ||||||||
| OtherFirstName: | PHELAN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 TALCOTT NOTHC | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606796700 | ||||||||
| FaxNumber: | 8606796736 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 TALCOTT NOTHC | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606796700 | ||||||||
| FaxNumber: | 8606796736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 054356 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.