Provider Demographics
NPI:1225211436
Name:SOUTHALL, ELIZABETH TALEAS (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TALEAS
Last Name:SOUTHALL
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 934
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-0934
Mailing Address - Country:US
Mailing Address - Phone:617-552-5124
Mailing Address - Fax:888-317-2641
Practice Address - Street 1:720 WASHINGTON ST STE 603
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2476
Practice Address - Country:US
Practice Address - Phone:617-306-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212052104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker