Provider Demographics
NPI:1972687440
Name:MOES, ELISABETH (PHD, ABPP/ABCN)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:
Last Name:MOES
Suffix:
Gender:F
Credentials:PHD, ABPP/ABCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4414
Mailing Address - Country:US
Mailing Address - Phone:617-522-7061
Mailing Address - Fax:617-739-7111
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-232-6305
Practice Address - Fax:617-739-7111
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3569103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03713Medicare ID - Type Unspecified
MAR89414Medicare UPIN