Provider Demographics
NPI:1679510481
Name:PRISLOE, EDITH M (MSW)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:M
Last Name:PRISLOE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BAYONET ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2600
Mailing Address - Country:US
Mailing Address - Phone:860-443-4163
Mailing Address - Fax:860-437-3926
Practice Address - Street 1:400 BAYONET ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2600
Practice Address - Country:US
Practice Address - Phone:860-443-4163
Practice Address - Fax:860-437-3926
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0033581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT80001180Medicare ID - Type Unspecified