Provider Demographics
NPI:1972682185
Name:WASSERMAN, ELAINE A (MSW LICSW ACSW MAC C)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:A
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:MSW LICSW ACSW MAC C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-587-0815
Mailing Address - Fax:508-580-4526
Practice Address - Street 1:686 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-587-0815
Practice Address - Fax:508-586-9446
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02669Medicare ID - Type Unspecified