Provider Demographics
NPI:1194188177
Name:KREIDA, ELLEN (LICSW, MPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KREIDA
Suffix:
Gender:F
Credentials:LICSW, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1193871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical