Provider Demographics
NPI:1164586459
Name:HERMANOS, ELLEN B (LICSW)
Entity Type:Individual
Prefix:MISS
First Name:ELLEN
Middle Name:B
Last Name:HERMANOS
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 1:11 OAK ST UNIT 64
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-4735
Mailing Address - Country:US
Mailing Address - Phone:774-520-0236
Mailing Address - Fax:
Practice Address - Street 1:11 OAK ST UNIT 64
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-4735
Practice Address - Country:US
Practice Address - Phone:774-520-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1107411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23676Medicare ID - Type Unspecified