Provider Demographics
NPI:1700928280
Name:CALKINS, ELLEN ROUNTREE (MSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:ROUNTREE
Last Name:CALKINS
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 1:758 BROAD STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1345
Mailing Address - Country:US
Mailing Address - Phone:860-442-6218
Mailing Address - Fax:860-447-2477
Practice Address - Street 1:758 BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1345
Practice Address - Country:US
Practice Address - Phone:860-442-6218
Practice Address - Fax:860-447-2477
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004179215Medicaid
CTR38871Medicare UPIN
CT004179215Medicaid