Basic Information
Provider Information | |||||||||
NPI: | 1992727036 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLOCCIA | ||||||||
FirstName: | ELINOR | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VENNOLA | ||||||||
OtherFirstName: | ELLEN | ||||||||
OtherMiddleName: | G | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 84 CANAL RD | ||||||||
Address2: |   | ||||||||
City: | GRANBY | ||||||||
State: | CT | ||||||||
PostalCode: | 060352220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609043089 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 599 FARMINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060322356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608377250 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2853 | CT | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 002853 | CT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.