=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407293277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINE RENEE TAVANI LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2013
-----------------------------------------------------
Last Update Date | 10/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 S HIGHLAND ST
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06119-1826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-916-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 RIVENDELL RD
-----------------------------------------------------
City | MARLBOROUGH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06447-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-228-4505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001521
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------