Healthcare Provider Details

I. General information

NPI: 1922419894
Provider Name (Legal Business Name): MS. TIANT SHANTA ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 EDWARDS ST.
NW HAVEN CT
06511
US

IV. Provider business mailing address

199 VALLEY ST
NEW HAVEN CT
06515-1213
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-8648
  • Fax:
Mailing address:
  • Phone: 203-215-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number247087391
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: