Provider Demographics
NPI:1609189760
Name:ABRAHAM, ELONZO STAFON JR (MED, CACI)
Entity Type:Individual
Prefix:MR
First Name:ELONZO
Middle Name:STAFON
Last Name:ABRAHAM
Suffix:JR
Gender:M
Credentials:MED, CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2717
Mailing Address - Country:US
Mailing Address - Phone:617-442-1499
Mailing Address - Fax:617-442-1660
Practice Address - Street 1:99 TOPEKA ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2717
Practice Address - Country:US
Practice Address - Phone:617-442-1499
Practice Address - Fax:617-442-1660
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0902231101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)