Provider Demographics
NPI:1033340559
Name:ELLISON, PRISCILLA L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:L
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:PIPPI
Other - Middle Name:L
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:15 VALENTINE ST
Mailing Address - Street 2:#8
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4032
Mailing Address - Country:US
Mailing Address - Phone:617-661-0021
Mailing Address - Fax:
Practice Address - Street 1:328 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1840
Practice Address - Country:US
Practice Address - Phone:617-661-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4855103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical