Provider Demographics
NPI:1780760165
Name:ELLISON, ELIZABETH REAVES (ATR, LICSW)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:REAVES
Last Name:ELLISON
Suffix:
Gender:F
Credentials:ATR, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SANTUIT POND RD
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-2422
Mailing Address - Country:US
Mailing Address - Phone:508-477-3635
Mailing Address - Fax:
Practice Address - Street 1:310 BARNSTABLE RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2902
Practice Address - Country:US
Practice Address - Phone:508-862-0514
Practice Address - Fax:508-862-9184
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10278781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP21357Medicare ID - Type Unspecified
MAPO8139Medicare UPIN