Provider Demographics
NPI:1174559165
Name:GARRETT, AUDREY (MD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NYE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1281
Mailing Address - Country:US
Mailing Address - Phone:860-657-3056
Mailing Address - Fax:860-633-3517
Practice Address - Street 1:55 NYE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1281
Practice Address - Country:US
Practice Address - Phone:860-657-3056
Practice Address - Fax:860-633-3517
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0320452084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF40894Medicare UPIN
CT260002406Medicare ID - Type UnspecifiedMEDICARE