MEDICARE: MS. LEWANDA MONIC ELLIOTT M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1164676961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LEWANDA MONIC ELLIOTT M.ED.

Provider Business Mailing Address
First Line	:	32 BISHOP JOE L SMITH WAY
Second Line	:	APARTMENT 303
City	:	DORCHESTER
State	:	MA
Zip	:	02121-3194
Country	:	US
Telephone Number	:	617-938-3412
Fax Number	:	617-938-3630

Provider Business Practice Location Address
First Line	:	1960 WASHINGTON ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-3219
Country	:	US
Telephone Number	:	617-516-0280
Fax Number	:	617-516-0281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2008
Last Update Date	:	11/06/2008

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