Provider Demographics
NPI:1902248693
Name:LINDQUIST, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:LINDQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 SHAKER RD STE 7
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3110
Mailing Address - Country:US
Mailing Address - Phone:860-749-2243
Mailing Address - Fax:860-749-2613
Practice Address - Street 1:72 SHAKER RD STE 7
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3110
Practice Address - Country:US
Practice Address - Phone:860-749-2243
Practice Address - Fax:860-749-2613
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional