Provider Demographics
NPI:1790892313
Name:ELLIS, BEVERLEY HEIDI (PHD)
Entity Type:Individual
Prefix:
First Name:BEVERLEY
Middle Name:HEIDI
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:DOWLING 1N
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:617-414-2664
Mailing Address - Fax:617-414-7534
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:DOWLING 1N
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-2664
Practice Address - Fax:617-414-7534
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA8105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist