Provider Demographics
NPI:1528404332
Name:KU, ELYSSA BRIANN WEBER
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:BRIANN WEBER
Last Name:KU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 ACCESS RD STE 24
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5233
Mailing Address - Country:US
Mailing Address - Phone:781-551-0999
Mailing Address - Fax:
Practice Address - Street 1:89 ACCESS RD STE 24
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5233
Practice Address - Country:US
Practice Address - Phone:815-551-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11387103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist