Provider Demographics
NPI:1316015464
Name:KIRSCHBLUM, ELYSE (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:KIRSCHBLUM
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 WAWECUS ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2160
Mailing Address - Country:US
Mailing Address - Phone:860-886-6610
Mailing Address - Fax:860-886-6664
Practice Address - Street 1:36 WATSON ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2122
Practice Address - Country:US
Practice Address - Phone:860-456-0287
Practice Address - Fax:860-456-3532
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000208237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316015464Medicaid