Provider Demographics
NPI:1528142742
Name:ELDRIDGE, SALLY R (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:R
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268-0131
Mailing Address - Country:US
Mailing Address - Phone:860-644-0305
Mailing Address - Fax:
Practice Address - Street 1:18 DOG LN STE A
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06268-2225
Practice Address - Country:US
Practice Address - Phone:860-644-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000847106H00000X
CT3406103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist