Healthcare Provider Details

I. General information

NPI: 1902357999
Provider Name (Legal Business Name): ELLEN WALTMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MANSFIELD AVE
WILLIMANTIC CT
06226-2027
US

IV. Provider business mailing address

132 MANSFIELD AVE
WILLIMANTIC CT
06226-2027
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-2261
  • Fax: 860-450-1357
Mailing address:
  • Phone: 860-456-2261
  • Fax: 860-450-1357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002290
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: