Provider Demographics
NPI:1861719643
Name:ELLIS, TARA (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SMOLLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:575 MAIN ST 2ND FLOOR
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:890-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:675 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2718
Practice Address - Country:US
Practice Address - Phone:890-347-6971
Practice Address - Fax:860-343-7379
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008023083Medicaid
071802Medicare PIN