Basic Information
| Provider Information | |||||||||
| NPI: | 1871160390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALCE-PELLERIN | ||||||||
| FirstName: | SHAWNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607747501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11496 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 008103133 | 05 | CT | MEDICAID |