Basic Information
| Provider Information | |||||||||
| NPI: | 1902034986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACGREGOR | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331 WETHERSFIELD AVE | ||||||||
| Address2: | ADULT SERVICES | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602364511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 331 WETHERSFIELD AVE | ||||||||
| Address2: | ADULT SERVICES | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602364511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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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 | 103T00000X | 003529 | CT | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | CPH003609 | 05 | CT | MEDICAID |