Provider Demographics
NPI:1407293277
Name:TAVANI, ELAINE RENEE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:RENEE
Last Name:TAVANI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 RIVENDELL RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-1260
Mailing Address - Country:US
Mailing Address - Phone:860-228-4505
Mailing Address - Fax:
Practice Address - Street 1:17 S HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1826
Practice Address - Country:US
Practice Address - Phone:860-916-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001521106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057772Medicaid