Provider Demographics
NPI:1043007792
Name:GLASTONBURY PEDIATRIC NEUROPSYCHOLOGY
Entity type:Organization
Organization Name:GLASTONBURY PEDIATRIC NEUROPSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MRAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-430-2736
Mailing Address - Street 1:78 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4325
Mailing Address - Country:US
Mailing Address - Phone:860-430-2736
Mailing Address - Fax:
Practice Address - Street 1:78 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4325
Practice Address - Country:US
Practice Address - Phone:860-430-2736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty