Provider Demographics
NPI:1912125733
Name:LISKOV, ELLEN BETH (RD, MPH, CDE)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:BETH
Last Name:LISKOV
Suffix:
Gender:F
Credentials:RD, MPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3448
Mailing Address - Country:US
Mailing Address - Phone:203-783-1387
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:CBB 52
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2422
Practice Address - Fax:203-688-2141
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02658Medicare ID - Type UnspecifiedYNHH MEDICARE NUMBER