Healthcare Provider Details

I. General information

NPI: 1245312727
Provider Name (Legal Business Name): ELAINE VIRGINIA DEA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 KIRTLAND STREET
BEDFORD MA
01731-2139
US

IV. Provider business mailing address

7 HART RD
CHELMSFORD MA
01824-4344
US

V. Phone/Fax

Practice location:
  • Phone: 781-377-2418
  • Fax: 781-377-4385
Mailing address:
  • Phone: 978-256-4771
  • Fax: 781-377-4385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number101YA0400X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: