Basic Information
| Provider Information | |||||||||
| NPI: | 1346245420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOBULINSKI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1202 LARSON DR | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068107379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037433973 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 280 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CHESHIRE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608706385 | ||||||||
| FaxNumber: | 2032500191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CT002359 | CT | N | Other Service Providers | Specialist | 2084N0400X | CT002359 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 103G00000X | CT002359 | CT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 7226563 | 01 | CT | AETNA | OTHER | 060002359CT01 | 01 | CT | ANTHEM | OTHER |