Organization
INTEGRATIVE PSYCHOLOGICAL CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RANDALL WALLACE PSYD (OWNER/PSYCHOLOGIST)
(860) 466-9411
Entity
Organization
Contact information
Practice address
44 CAPITOL AVE STE 402, HARTFORD, CT 06106-1764
(860) 466-9411
Mailing address
40 MOUNTAIN RD, WEST HARTFORD, CT 06107-2913
(860) 466-9411
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
103TC0700X
Clinical Psychologist
—
—
103TF0200X
Forensic Psychologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008042490
—
CT
Enumeration date
12/26/2018
Last updated
12/26/2018
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