Provider Demographics
NPI:1184665192
Name:ELLIOTT, MARTIELE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARTIELE
Middle Name:
Last Name:ELLIOTT
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:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:GT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230
Mailing Address - Country:US
Mailing Address - Phone:413-717-0193
Mailing Address - Fax:
Practice Address - Street 1:58 OLD NORTH RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MA
Practice Address - Zip Code:01098
Practice Address - Country:US
Practice Address - Phone:413-238-5511
Practice Address - Fax:413-238-5358
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1110751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1302467Medicaid
OTH000Medicare UPIN