Provider Demographics
NPI:1063684074
Name:MAMBRINO, ELISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:MAMBRINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6086
Mailing Address - Country:US
Mailing Address - Phone:203-536-5907
Mailing Address - Fax:
Practice Address - Street 1:500 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6086
Practice Address - Country:US
Practice Address - Phone:203-536-5907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002803103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist