Provider Demographics
NPI:1326182353
Name:CHESEBROUGH, ELDA STOREY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ELDA
Middle Name:STOREY
Last Name:CHESEBROUGH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WILCOX RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2614
Mailing Address - Country:US
Mailing Address - Phone:860-572-4969
Mailing Address - Fax:860-572-5767
Practice Address - Street 1:107 WILCOX RD
Practice Address - Street 2:SUITE 111
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-2614
Practice Address - Country:US
Practice Address - Phone:860-572-4969
Practice Address - Fax:860-572-5767
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0056491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004256849Medicaid
CT11342489Medicare UPIN
CT004256849Medicaid
CT140005649CT02Medicare UPIN
CT11-3783122Medicare UPIN