Healthcare Provider Details

I. General information

NPI: 1851921340
Provider Name (Legal Business Name): SHAWN TARDIF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 CENTER ST
MANCHESTER CT
06040-3926
US

IV. Provider business mailing address

1317 EAST ST APT 315
NEW BRITAIN CT
06053-2582
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-3888
  • Fax:
Mailing address:
  • Phone: 860-967-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: