Provider Demographics
NPI:1134565856
Name:EANNIELLO, ELIZABETH R (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:EANNIELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 WASHINGTON ST
Mailing Address - Street 2:SUITE 2 ARBORETUM PLACE
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3745
Mailing Address - Country:US
Mailing Address - Phone:617-983-5856
Mailing Address - Fax:617-983-5854
Practice Address - Street 1:3815 WASHINGTON ST
Practice Address - Street 2:SUITE 2 ARBORETUM PLACE
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3745
Practice Address - Country:US
Practice Address - Phone:617-983-5856
Practice Address - Fax:617-983-5854
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303414Medicaid