Provider Demographics
NPI:1558938142
Name:EZZO, SHILOH RAE (MS, LPCA)
Entity Type:Individual
Prefix:
First Name:SHILOH
Middle Name:RAE
Last Name:EZZO
Suffix:
Gender:F
Credentials:MS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 LAZY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1731
Mailing Address - Country:US
Mailing Address - Phone:860-301-8544
Mailing Address - Fax:
Practice Address - Street 1:586 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-1812
Practice Address - Country:US
Practice Address - Phone:860-225-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4451101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional