Healthcare Provider Details

I. General information

NPI: 1003238072
Provider Name (Legal Business Name): ELLEN COLOCCIA, PSY D LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 CANAL RD
GRANBY CT
06035-2220
US

IV. Provider business mailing address

84 CANAL RD
GRANBY CT
06035-2220
US

V. Phone/Fax

Practice location:
  • Phone: 860-904-3089
  • Fax:
Mailing address:
  • Phone: 860-904-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2853
License Number StateCT

VIII. Authorized Official

Name: DR. ELLEN G COLOCCIA
Title or Position: OWNER
Credential: PSY D
Phone: 860-633-2810