Provider Demographics
NPI:1174502686
Name:GEYSEN, GEORGE (PSYD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GEYSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SCHOOL ST STE 3
Mailing Address - Street 2:CHANGEPOINT, LLC
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4552
Mailing Address - Country:US
Mailing Address - Phone:860-633-0703
Mailing Address - Fax:860-633-1741
Practice Address - Street 1:18 SCHOOL ST STE 3
Practice Address - Street 2:CHANGEPOINT, LLC
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4552
Practice Address - Country:US
Practice Address - Phone:860-633-0703
Practice Address - Fax:860-633-1741
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004230885Medicaid
CT004230885Medicaid