Provider Demographics
NPI:1255350161
Name:AUSTIN, ELLEN EGAN (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:EGAN
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:22 MILL ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:781-646-5726
Mailing Address - Fax:781-641-4864
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-646-5726
Practice Address - Fax:781-641-4864
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10206151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA722116OtherTUFTS HEALTH PLAN
MAP06060OtherBLUE CROSS BLUE SHIELD MA
MAS021915OtherCHAMPUS
MAS021915OtherCHAMPUS