Provider Demographics
NPI:1700017829
Name:MONGILLO-HERMAN, ELIZABETH A (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:MONGILLO-HERMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:MONGILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:784 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:784 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1619
Practice Address - Country:US
Practice Address - Phone:860-523-4450
Practice Address - Fax:860-523-9537
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9381103TC0700X
CT003111103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008045664Medicaid
CT008045664Medicaid