Provider Demographics
NPI:1134248933
Name:LITCOFSKY DIAMOND, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LITCOFSKY DIAMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:LITCOFSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:174 BAY STATE ROAD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1502
Mailing Address - Country:US
Mailing Address - Phone:617-266-2730
Mailing Address - Fax:617-742-0257
Practice Address - Street 1:127 MOUNT AUBURN STREET
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-266-2730
Practice Address - Fax:617-742-0257
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1051941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03603Medicare ID - Type Unspecified