Basic Information
| Provider Information | |||||||||
| NPI: | 1538110614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEODOR SHIBLES | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THEODOR | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 RESEARCH PKWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064754214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 LANGLEY RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024591972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 7026 | MA | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 7026 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 009601 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.