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General NPI Number Information
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NPI Number | 1053656777
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Entity Type | Individual
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Provider Name | ETHAN SANSOLO LCSW
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Gender | Male
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Dates
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Enumeration Date | 12/06/2012
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Last Update Date | 12/06/2012
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Provider Practice Location Address
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Address Line | 407 HIGHLAND AVE, BUILDING A SUITE 6
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City | CHESHIRE
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State | CT
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Zip | 06410
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Country | US
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Telephone | 860-335-7615
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Fax |
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Provider Business Mailing Address
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Address Line | 45 JIMMY LN
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City | MERIDEN
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State | CT
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Zip | 06450-7200
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Country | US
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Telephone | 203-440-2351
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 58.008167
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License Number State | CT
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