Basic Information
| Provider Information | |||||||||
| NPI: | 1649548082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NODELMAN | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | |||||||||
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| Credential: | LADC, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | STE321 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 184 FRONT AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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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 | 101YA0400X | 000973 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 008038052 | 05 | CT | MEDICAID |