Provider Demographics
NPI:1508479106
Name:REAL, TERRY ELLIS (LICSW)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ELLIS
Last Name:REAL
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 1:291 NAHANTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2900
Mailing Address - Country:US
Mailing Address - Phone:617-965-3023
Mailing Address - Fax:
Practice Address - Street 1:754 MASSACHUSETTS AVENE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476
Practice Address - Country:US
Practice Address - Phone:781-646-7326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1046741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical