Provider Demographics
NPI:1285636159
Name:BUCHANAN, ELISABETH S (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:S
Last Name:BUCHANAN
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 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:857-364-2226
Mailing Address - Fax:857-364-2226
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-2226
Practice Address - Fax:857-364-2226
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38523104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1718645Medicaid
TX87443QOtherBCBS TEXAS
TX8D3297Medicare ID - Type Unspecified