Provider Demographics
NPI:1912364555
Name:MARTIN, ELLEN P
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2600
Mailing Address - Country:US
Mailing Address - Phone:617-419-3408
Mailing Address - Fax:617-534-2611
Practice Address - Street 1:201 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2713
Practice Address - Country:US
Practice Address - Phone:617-534-6191
Practice Address - Fax:857-288-2200
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW 1173521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical