Provider Demographics
NPI:1801378344
Name:ELLENTUCK, AMY (LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ELLENTUCK
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 1:50 FR MORISSETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1037
Mailing Address - Country:US
Mailing Address - Phone:789-275-6320
Mailing Address - Fax:
Practice Address - Street 1:50 FR MORISSETTE BLVD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1037
Practice Address - Country:US
Practice Address - Phone:781-640-8094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10163021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical