Basic Information
Provider Information | |||||||||
NPI: | 1770865883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTANDREU MIRABAL | ||||||||
FirstName: | MARIAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANTANDREU | ||||||||
OtherFirstName: | MARIAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 125 LIBERTY ST STE 102 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011031109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4132004110 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 132 JEFFERSON STREET | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 06106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609720200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2011 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 9906 | MA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 4020 | CT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.