Provider Demographics
NPI:1124101480
Name:HERNANDEZ, ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BARTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-1130
Mailing Address - Country:US
Mailing Address - Phone:860-478-2229
Mailing Address - Fax:
Practice Address - Street 1:56 ARBOR ST STE 215
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1201
Practice Address - Country:US
Practice Address - Phone:860-233-1345
Practice Address - Fax:860-233-1346
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0050141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140005014CT02OtherANTHEM BEHAVIORAL HEALTH
CTP3513598OtherOXFORD
CT11242719OtherCAQH