Provider Demographics
NPI:1003110032
Name:GOTTESMAN, ELISE BLOCK (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:BLOCK
Last Name:GOTTESMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BICKFORD ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1401
Mailing Address - Country:US
Mailing Address - Phone:617-971-2100
Mailing Address - Fax:617-983-1377
Practice Address - Street 1:75 BICKFORD ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1401
Practice Address - Country:US
Practice Address - Phone:617-971-2100
Practice Address - Fax:617-983-1377
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1119291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical