Provider Demographics
NPI:1053615534
Name:LARRY BILKER, PH.D., LLC
Entity type:Organization
Organization Name:LARRY BILKER, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BILKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-453-4446
Mailing Address - Street 1:296 VALLEY SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2147
Mailing Address - Country:US
Mailing Address - Phone:203-453-4446
Mailing Address - Fax:
Practice Address - Street 1:296 VALLEY SHORE DR
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2147
Practice Address - Country:US
Practice Address - Phone:203-453-4446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004051918Medicaid
CT004051918Medicaid