Provider Demographics
NPI:1558626903
Name:HALLISEY, ELAINE MARY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARY
Last Name:HALLISEY
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 1:63 WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3160
Mailing Address - Country:US
Mailing Address - Phone:508-586-7518
Mailing Address - Fax:
Practice Address - Street 1:63 WHEELER AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-3160
Practice Address - Country:US
Practice Address - Phone:508-586-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020588101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty