Provider Demographics
NPI:1831204932
Name:NANNIS, ELLEN D (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:D
Last Name:NANNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6824
Mailing Address - Country:US
Mailing Address - Phone:781-861-1818
Mailing Address - Fax:781-861-2057
Practice Address - Street 1:57 BEDFORD ST
Practice Address - Street 2:SUITE 125
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4500
Practice Address - Country:US
Practice Address - Phone:781-861-1818
Practice Address - Fax:781-861-2057
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6950103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11434OtherOPTIONS PROVIDER NUMBER
MAW05477OtherBLUE CROSS PROVIDER NUMBE
MA755578OtherTUFTS PROVIDER NUMBER
MA755578OtherTUFTS PROVIDER NUMBER