Healthcare Provider Details

I. General information

NPI: 1184368078
Provider Name (Legal Business Name): MR. EWALD HAILE ERILUS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 CONGRESS ST
BOSTON MA
02210-1218
US

IV. Provider business mailing address

301 MAXFIELD ST
NEW BEDFORD MA
02740-4328
US

V. Phone/Fax

Practice location:
  • Phone: 617-790-4800
  • Fax:
Mailing address:
  • Phone: 857-204-5020
  • Fax: 617-297-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: