Healthcare Provider Details

I. General information

NPI: 1437896529
Provider Name (Legal Business Name): ELLEN HEDSTROM CLEGG LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRISON AVE STE 605
BOSTON MA
02111-1929
US

IV. Provider business mailing address

68 HARRISON AVE STE 605 PMB 107572
BOSTON MA
02111-1929
US

V. Phone/Fax

Practice location:
  • Phone: 781-488-1315
  • Fax:
Mailing address:
  • Phone: 781-488-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10002750
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: