Provider Demographics
NPI:1881871606
Name:FORMICA BURNHAM, ELAINE (LPC)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:
Last Name:FORMICA BURNHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-4217
Mailing Address - Country:US
Mailing Address - Phone:860-528-7005
Mailing Address - Fax:
Practice Address - Street 1:378 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-4217
Practice Address - Country:US
Practice Address - Phone:860-528-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00698OtherLPC