Provider Demographics
NPI:1235104050
Name:CETLIN, NANCY RUTH (EDD)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:RUTH
Last Name:CETLIN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:MRS
Other - First Name:NANCY
Other - Middle Name:CETLIN
Other - Last Name:WILTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDD
Mailing Address - Street 1:141 BROOKS ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-254-0284
Mailing Address - Fax:617-782-6764
Practice Address - Street 1:264 BEACON ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:617-267-5433
Practice Address - Fax:617-782-6764
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3514103TC0700X
MI6301002901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001020601OtherMANAGED HEALTH NETWORK
VD6841OtherEMPIRE BCBS
6883946OtherVALUE/OPTIONS
A002908OtherVAL/H
0012255000OtherAETNA
MAW03627OtherBLUE CROSS
739159OtherTUFTS HEALTH PLAN
A002908OtherVALUE
W03627Medicare ID - Type Unspecified