Provider Demographics
NPI:1235268566
Name:FARIS, GERALD A (PHD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:FARIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185417
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-0417
Mailing Address - Country:US
Mailing Address - Phone:203-248-1513
Mailing Address - Fax:203-248-1513
Practice Address - Street 1:140 GLASTONBURY BLVD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4402
Practice Address - Country:US
Practice Address - Phone:860-633-7501
Practice Address - Fax:203-248-1513
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001277103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical