Organization
PROFESSIONAL RESOURCE GROUP PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARY P KANABAY PSYD (DIRECTOR PRESIDENT)
(860) 456-4604
Entity
Organization
Contact information
Practice address
207 STORRS RD # 174, MANSFIELD CENTER, CT 06250-1638
(860) 456-4604
(860) 456-1738
Mailing address
207 STORRS RD # 174, MANSFIELD CENTER, CT 06250-1638
(860) 456-4604
(860) 456-1738
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
—
CT
106H00000X
Marriage & Family Therapist
—
CT
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004255007
—
CT
05
—
004255057
—
CT
05
—
004398047
—
CT
05
—
008002985
—
CT
05
—
008033020
—
CT
01
—
297211
MHN
—
01
—
620000199
MEDICARE
CT
01
—
C007612
TRICARE
—
Enumeration date
03/12/2007
Last updated
05/01/2014
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