Provider Demographics
NPI:1689648420
Name:HENNEN, MALINDA ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:MALINDA
Middle Name:ANN
Last Name:HENNEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 ALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-2112
Mailing Address - Country:US
Mailing Address - Phone:203-389-6467
Mailing Address - Fax:
Practice Address - Street 1:190 ALDEN AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-2112
Practice Address - Country:US
Practice Address - Phone:203-389-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1069103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTR38551Medicare UPIN