Provider Demographics
NPI:1023497302
Name:SHORELINE PSYCHIATRIC
Entity type:Organization
Organization Name:SHORELINE PSYCHIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAZZARINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-871-1357
Mailing Address - Street 1:226 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3103
Mailing Address - Country:US
Mailing Address - Phone:203-871-1357
Mailing Address - Fax:203-488-5034
Practice Address - Street 1:226 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3103
Practice Address - Country:US
Practice Address - Phone:203-871-1357
Practice Address - Fax:203-488-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0342372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001342378Medicaid