NPIMap

Organization Active NPI

Professional Resource Group PC

  • Clinical Psychologist
  • Mansfield Center, CT
National Provider Identifier
1710019963
Registry record updated May 1, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
Legal business name
PROFESSIONAL RESOURCE GROUP PC
Practice address
207 Storrs Rd # 174
Mansfield Center, CT 06250-1638
Phone
(860) 456-4604
Fax
(860) 456-1738
NPI assigned
Mar 12, 2007
Last updated
May 1, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gary P Kanabay, PSYDNPI 1164521753
Title
Director President
Phone
(860) 456-4604

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X CT Primary
Marriage & Family TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 106H00000X CT
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X CT

Addresses

Primary practice location

207 Storrs Rd # 174
Mansfield Center, CT 06250-1638

Mailing address

207 Storrs Rd # 174
Mansfield Center, CT 06250-1638
Phone (860) 456-4604

Other identifiers 8

IdentifierTypeStateIssuer
004398047MedicaidCT
008002985MedicaidCT
004255057MedicaidCT
620000199OtherCTMEDICARE
008033020MedicaidCT
297211OtherMHN
C007612OtherTRICARE
004255007MedicaidCT

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173657600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398902400000",
    "number": "1710019963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "207 STORRS RD # 174",
            "city": "MANSFIELD CENTER",
            "state": "CT",
            "postal_code": "062501638",
            "telephone_number": "860-456-4604",
            "fax_number": "860-456-1738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "207 STORRS RD # 174",
            "city": "MANSFIELD CENTER",
            "state": "CT",
            "postal_code": "062501638",
            "telephone_number": "860-456-4604",
            "fax_number": "860-456-1738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL RESOURCE GROUP PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-12",
        "last_updated": "2014-05-01",
        "status": "A",
        "authorized_official_last_name": "KANABAY",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "DIRECTOR PRESIDENT",
        "authorized_official_telephone_number": "860-456-4604",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "CT",
            "license": null,
            "primary": true
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Marriage & Family Therapist",
            "state": "CT",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "CT",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004398047",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008002985",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004255057",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "620000199",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008033020",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MHN",
            "identifier": "297211",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "C007612",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004255007",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mansfield Center, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.