Provider Demographics
NPI:1487210662
Name:MATRISCIANO, ELISSA ANN
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:ANN
Last Name:MATRISCIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-6617
Mailing Address - Country:US
Mailing Address - Phone:845-222-3898
Mailing Address - Fax:
Practice Address - Street 1:131 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1605
Practice Address - Country:US
Practice Address - Phone:845-222-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5156104100000X
CT1691103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker