Provider Demographics
NPI:1407427552
Name:PASTERNAK, ELENA (PHD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:PASTERNAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 SW ARCHER RD APT 4068
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1028
Mailing Address - Country:US
Mailing Address - Phone:516-458-2803
Mailing Address - Fax:
Practice Address - Street 1:1 BOWDOIN SQ FL 7
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2927
Practice Address - Country:US
Practice Address - Phone:617-726-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
MA11586103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist