Provider Demographics
NPI:1366461337
Name:ELLIS, ROBERT EARLE (LICSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EARLE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02188-2202
Mailing Address - Country:US
Mailing Address - Phone:781-812-0252
Mailing Address - Fax:781-812-0252
Practice Address - Street 1:273 FRONT ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02188-2202
Practice Address - Country:US
Practice Address - Phone:781-812-0252
Practice Address - Fax:781-812-0252
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022916101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health