Provider Demographics
NPI:1588671945
Name:CONNERS, ELAINE RUTH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:RUTH
Last Name:CONNERS
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 1:947 ROUTE 6A
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02675-2171
Mailing Address - Country:US
Mailing Address - Phone:508-362-3930
Mailing Address - Fax:508-362-3930
Practice Address - Street 1:947 ROUTE 6A
Practice Address - Street 2:
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675-2171
Practice Address - Country:US
Practice Address - Phone:508-362-3930
Practice Address - Fax:508-362-3930
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1028251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1857703Medicaid
MAP05431Medicare ID - Type Unspecified
MA014176Medicare UPIN
MA211649Medicare UPIN
MA000000030835Medicare UPIN
MA1890085Medicare UPIN
MA1857703Medicaid