Provider Demographics
NPI:1366460891
Name:ELIN, MARK RANDOLPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RANDOLPH
Last Name:ELIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CONVERSE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1760
Mailing Address - Country:US
Mailing Address - Phone:413-567-9244
Mailing Address - Fax:
Practice Address - Street 1:1200 CONVERSE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1760
Practice Address - Country:US
Practice Address - Phone:413-567-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4026103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0522589Medicaid
MAW04081Medicare ID - Type Unspecified
MA0522589Medicaid