Healthcare Provider Details

I. General information

NPI: 1487323010
Provider Name (Legal Business Name): ELISSA SELANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELISSA BRENNER

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N MAIN ST
SOUTHINGTON CT
06489-2513
US

IV. Provider business mailing address

115 N MAIN ST
SOUTHINGTON CT
06489-2513
US

V. Phone/Fax

Practice location:
  • Phone: 860-281-2280
  • Fax: 860-499-3514
Mailing address:
  • Phone: 860-281-2280
  • Fax: 860-499-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002678
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: