Basic Information
| Provider Information | |||||||||
| NPI: | 1114313947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALTA | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LCSW,MSW,BSW,ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6022 | CT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0808064941 | 05 | CT | MEDICAID | 13818187 | 01 | CT | CAQH | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH/OFORD FREEDOM-LIBERTY GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH/CONNECTICTUT GRP/FACILITY | OTHER | D339210 402 E MAIN | 01 | CT | BEACON HEALTH STRATEGIES | OTHER | PENDING | 01 | CT | MHN TRICARE NORTH | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | 060669107 | 01 | CT | HEALTHYCT GRP/FACILITY | OTHER | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH GRP/FACILITY | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE GRP/FACILITY | OTHER |