Healthcare Provider Details

I. General information

NPI: 1083171508
Provider Name (Legal Business Name): SHEILA PURUSHOTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WHITNEY AVE
HAMDEN CT
06517-2459
US

IV. Provider business mailing address

96 BRISTOL STREET EXT
BRANFORD CT
06405-4843
US

V. Phone/Fax

Practice location:
  • Phone: 203-248-2116
  • Fax: 203-287-9815
Mailing address:
  • Phone: 203-752-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10484
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: