Basic Information
| Provider Information | |||||||||
| NPI: | 1265803407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELINTUKONIS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOIVIN | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062260858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602370261 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 317 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606432101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 009175 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.