Healthcare Provider Details

I. General information

NPI: 1588671945
Provider Name (Legal Business Name): ELAINE RUTH CONNERS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 ROUTE 6A
YARMOUTH PORT MA
02675-2171
US

IV. Provider business mailing address

947 ROUTE 6A
YARMOUTH PORT MA
02675-2171
US

V. Phone/Fax

Practice location:
  • Phone: 508-362-3930
  • Fax: 508-362-3930
Mailing address:
  • Phone: 508-362-3930
  • Fax: 508-362-3930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102825
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: