Provider Demographics
NPI:1093884306
Name:ROTTERSMANN, ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ROTTERSMANN
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 1:3464 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2665
Mailing Address - Country:US
Mailing Address - Phone:617-320-0647
Mailing Address - Fax:
Practice Address - Street 1:3464 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2665
Practice Address - Country:US
Practice Address - Phone:617-320-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10262081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303546Medicaid
MA221867Medicare Oscar/Certification
MA1303546Medicaid