Provider Demographics
NPI:1821360512
Name:SAMELA, TAYLOR SOMMERVILLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:SOMMERVILLE
Last Name:SAMELA
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 1:1 COLONY ST
Mailing Address - Street 2:CONNECTICUT JUNIOR REPUBLIC
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-3210
Mailing Address - Country:US
Mailing Address - Phone:203-440-4622
Mailing Address - Fax:203-440-4625
Practice Address - Street 1:1 COLONY ST
Practice Address - Street 2:CONNECTICUT JUNIOR REPUBLIC
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-3210
Practice Address - Country:US
Practice Address - Phone:203-440-4622
Practice Address - Fax:203-440-4625
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0090741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004068284Medicaid