Healthcare Provider Details

I. General information

NPI: 1235440199
Provider Name (Legal Business Name): ELLEN LYDIA SANTANIELLO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MAYFLOWER ST
PROVIDENCE RI
02906-3521
US

IV. Provider business mailing address

11 MAYFLOWER ST
PROVIDENCE RI
02906-3521
US

V. Phone/Fax

Practice location:
  • Phone: 401-316-3226
  • Fax: 401-331-5772
Mailing address:
  • Phone: 401-316-3226
  • Fax: 401-331-5772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00552
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: