Provider Demographics
NPI:1336201367
Name:BASSUK, ELLEN L (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:BASSUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MONTVALE RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1363
Mailing Address - Country:US
Mailing Address - Phone:617-964-3834
Mailing Address - Fax:
Practice Address - Street 1:CENTER ON FAMILY HOMELESSNESS
Practice Address - Street 2:181 WELLS AVENUE
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459
Practice Address - Country:US
Practice Address - Phone:617-964-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA316882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry