Provider Demographics
NPI:1083788806
Name:BURSACK, ELLIOTT S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:S
Last Name:BURSACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 AVON HILL ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-3609
Mailing Address - Country:US
Mailing Address - Phone:617-547-4823
Mailing Address - Fax:617-848-0168
Practice Address - Street 1:51 AVON HILL ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-3609
Practice Address - Country:US
Practice Address - Phone:617-547-4823
Practice Address - Fax:617-848-0168
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA781103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50506Medicare ID - Type UnspecifiedMENTAL HEALTH PROVIDER #