=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164653267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE A SILVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2009
-----------------------------------------------------
Last Update Date | 08/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 DIXWELL AVENUE
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-503-6345
-----------------------------------------------------
Fax | 203-503-3451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 DIXWELL AVENUE
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-503-6345
-----------------------------------------------------
Fax | 203-503-3451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 002806
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------