MEDICARE: ELIZABETH M. SHEA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8767	CT

General Provider Information

NPI Number	:	1043617806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH M. SHEA LCSW

Provider Business Mailing Address
First Line	:	310 MAIN ST LOWR LEVEL
Second Line	:
City	:	EAST HAVEN
State	:	CT
Zip	:	06512-2919
Country	:	US
Telephone Number	:	203-444-7778
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 MAIN ST LOWR LEVEL
Second Line	:
City	:	EAST HAVEN
State	:	CT
Zip	:	06512-2919
Country	:	US
Telephone Number	:	203-444-7778
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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