Provider Demographics
NPI:1518022201
Name:KATZ, ELLIS H
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:H
Last Name:KATZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ESSEX GREEN DR
Mailing Address - Street 2:SUITE 65
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2961
Mailing Address - Country:US
Mailing Address - Phone:978-531-5571
Mailing Address - Fax:
Practice Address - Street 1:7 ESSEX GREEN DR
Practice Address - Street 2:SUITE 65
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2961
Practice Address - Country:US
Practice Address - Phone:978-531-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2970103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0525588Medicaid
MA0525588Medicaid