Provider Demographics
NPI:1922419894
Name:ELLISON, TIANT SHANTA
Entity Type:Individual
Prefix:MS
First Name:TIANT
Middle Name:SHANTA
Last Name:ELLISON
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 1:199 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1213
Mailing Address - Country:US
Mailing Address - Phone:203-215-9101
Mailing Address - Fax:
Practice Address - Street 1:93 EDWARDS ST.
Practice Address - Street 2:
Practice Address - City:NW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-777-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT247087391101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor