Provider Demographics
NPI:1831181296
Name:JOST, ELAINE BLACK (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:BLACK
Last Name:JOST
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 1:14 APPLETON TER
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3556
Mailing Address - Country:US
Mailing Address - Phone:617-969-9877
Mailing Address - Fax:617-924-4647
Practice Address - Street 1:14 APPLETON TER
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3556
Practice Address - Country:US
Practice Address - Phone:617-969-9877
Practice Address - Fax:617-924-4647
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105526101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04762Medicare ID - Type Unspecified