Provider Demographics
NPI:1861861429
Name:ELLIS, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ELLIS
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 1:995 DAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1722
Mailing Address - Country:US
Mailing Address - Phone:860-731-5522
Mailing Address - Fax:860-731-5536
Practice Address - Street 1:487 CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3982
Practice Address - Country:US
Practice Address - Phone:860-432-8775
Practice Address - Fax:860-432-8581
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor