Provider Demographics
NPI:1245512581
Name:EMELYANOV, SVETLANA (LICSW)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:EMELYANOV
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:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-6901
Mailing Address - Country:US
Mailing Address - Phone:978-394-2109
Mailing Address - Fax:
Practice Address - Street 1:234 LITTLETON RD STE 1D
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3530
Practice Address - Country:US
Practice Address - Phone:978-394-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1196301041C0700X
NH19491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303414Medicaid