=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487109252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELATION WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2016
-----------------------------------------------------
Last Update Date | 04/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057 BROAD ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06604-4219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-661-2925
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 248 TOBY HILL RD
-----------------------------------------------------
City | WESTBROOK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06498-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | MRS. MARIA CAMILA SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-308-7835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------