Basic Information
| Provider Information | |||||||||
| NPI: | 1255358230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORO-DE-CASILLAS | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PERKINS FARM DRIVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608861433 | ||||||||
| FaxNumber: | 8608864644 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PERKINS FARM DRIVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608706385 | ||||||||
| FaxNumber: | 8602450000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 44391 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD11991 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001443910 | 05 | CT | MEDICAID |