Basic Information
| Provider Information | |||||||||
| NPI: | 1376548867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHNIRMAN | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PERKINS FARM DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014864374 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 PERKINS FARM DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MYSTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063554041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608706385 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS00813 | RI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PS00813 | RI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | CT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 26685-1 | 01 | RI | RI BCBS PROVIDER ID | OTHER | 003971 | 01 | CT | CT LIC | OTHER | 411522 | 01 | RI | BLUE CHIP PROVIDER ID | OTHER |