Provider Demographics
NPI:1093751067
Name:EBLEN, TERRI (LPC)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:EBLEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 LITCHFIELD TPKE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1251
Mailing Address - Country:US
Mailing Address - Phone:203-387-3417
Mailing Address - Fax:
Practice Address - Street 1:949 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3142
Practice Address - Country:US
Practice Address - Phone:203-878-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT191073OtherMHN PROVIDER NUMBER