Healthcare Provider Details

I. General information

NPI: 1861719643
Provider Name (Legal Business Name): TARA ELLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA SMOLLEN LCSW

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 MAIN ST
MIDDLETOWN CT
06457-2718
US

IV. Provider business mailing address

575 MAIN ST 2ND FLOOR ATTN: CREDENTIALING DPT
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 890-347-6971
  • Fax: 860-343-7379
Mailing address:
  • Phone: 890-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007912
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: