| Doctor Name: | ETHAN SANSOLO |
| NPI Number: | 1053656777 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 58.008167 |
| Business Practice Address: | 407 Highland Ave, Building A Suite 6 Cheshire, CT - 06410 |
| Business Phone Number: | 8603357615 |
| Business Fax Number: | |
| Mailing Address: | 45 Jimmy Ln, MERIDEN |
| State: | CT |
| Postal Code: | 064507200 |
| Phone Number: | 2034402351 |
| Fax Number: | |
| NPI Enumeration Date: | 12/06/2012 |
| NPI Last Update Date: | 12/06/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 58.008167 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CT |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |