Provider Demographics
NPI:1497233795
Name:PORTER, ELIZABETH TRASK (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TRASK
Last Name:PORTER
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 1:41 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-1734
Mailing Address - Country:US
Mailing Address - Phone:781-956-5467
Mailing Address - Fax:
Practice Address - Street 1:175 NORTH BEACON STREET
Practice Address - Street 2:(LOWER SCHOOL PROGRAM)
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2790
Practice Address - Country:US
Practice Address - Phone:617-972-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10231271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical