Healthcare Provider Details

I. General information

NPI: 1659907103
Provider Name (Legal Business Name): JUSTIN ELLENBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE # LG065
FARMINGTON CT
06030-1956
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-1921
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4988
  • Fax: 860-679-3489
Mailing address:
  • Phone: 860-679-2147
  • Fax: 860-679-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: