Provider Demographics
NPI:1942862966
Name:WALTS, ELISA (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:WALTS
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 1:350 3RD ST UNIT 1701
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1143
Mailing Address - Country:US
Mailing Address - Phone:617-645-7838
Mailing Address - Fax:
Practice Address - Street 1:350 3RD ST UNIT 1701
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1143
Practice Address - Country:US
Practice Address - Phone:617-645-7838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1220861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical