Provider Demographics
NPI:1164970596
Name:DEJESUS, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LILLEY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01850
Mailing Address - Country:US
Mailing Address - Phone:978-726-7832
Mailing Address - Fax:
Practice Address - Street 1:10 BRIDGE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1268
Practice Address - Country:US
Practice Address - Phone:978-453-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1000015708025OtherMASSHEALTH