Basic Information
| Provider Information | |||||||||
| NPI: | 1184743551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROCK | ||||||||
| FirstName: | ELISE | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 MOUNT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064701537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034268103 | ||||||||
| FaxNumber: | 2034260550 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 MOUNT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064701537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034268103 | ||||||||
| FaxNumber: | 2034260550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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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 | 002446 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 77ABH0020CT01 | 01 | CT | ANTHEM BEHAVIORAL HEALTH | OTHER | ANC1319 | 01 | CT | OXFORD PROVIDER PIN | OTHER | 00412586200 | 05 | CT | MEDICAID | 248294 | 01 | CT | MHN GROUP | OTHER |