MEDICARE: RICHARD ZELISKO LCSW, LMFT

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	002045	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	140002012CT02	OTHER	CT	BCBS

General Provider Information

NPI Number	:	1326107855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD ZELISKO LCSW, LMFT

Provider Business Mailing Address
First Line	:	51 NORTH MAIN STREET
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489
Country	:	US
Telephone Number	:	203-988-8842
Fax Number	:	203-439-0557

Provider Business Practice Location Address
First Line	:	51 N MAIN ST
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2537
Country	:	US
Telephone Number	:	203-988-8842
Fax Number	:	203-439-0557

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

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	01/22/2010

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