Provider Demographics
NPI:1912117334
Name:ELLIOTT, MATTHEW ROGERS (PHD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROGERS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 SINGLETARY LN
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6128
Mailing Address - Country:US
Mailing Address - Phone:508-875-2236
Mailing Address - Fax:
Practice Address - Street 1:5 EDGELL ROAD
Practice Address - Street 2:SUITE 23
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701
Practice Address - Country:US
Practice Address - Phone:598-793-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2013-11-26
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2013-11-26
Provider Licenses
StateLicense IDTaxonomies
MA7494103T00000X, 103TB0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling