Provider Demographics
NPI:1467518043
Name:LANDAU, ELISE (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:LANDAU
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:PO BOX 812071
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-0013
Mailing Address - Country:US
Mailing Address - Phone:617-723-5817
Mailing Address - Fax:
Practice Address - Street 1:67 UNION ST
Practice Address - Street 2:M.O.B. SUITE 205
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-7700
Practice Address - Country:US
Practice Address - Phone:617-723-5817
Practice Address - Fax:508-647-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1049411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP03116OtherBLUE CROSS BLUE SHIELD