Provider Demographics
NPI:1063640910
Name:BAR-SHALOM, ELIANA
Entity Type:Individual
Prefix:
First Name:ELIANA
Middle Name:
Last Name:BAR-SHALOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06247-1320
Mailing Address - Country:US
Mailing Address - Phone:860-455-0707
Mailing Address - Fax:860-455-8002
Practice Address - Street 1:376 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06247-1320
Practice Address - Country:US
Practice Address - Phone:860-455-0707
Practice Address - Fax:860-455-8002
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001206OtherSPEECH