Healthcare Provider Details

I. General information

NPI: 1255017760
Provider Name (Legal Business Name): ELLEN EDUTU IJEBOR PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 E NEWTON ST
BOSTON MA
02118-3553
US

IV. Provider business mailing address

1363 BOYLSTON ST # 205
BOSTON MA
02215-3941
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4646
  • Fax:
Mailing address:
  • Phone: 956-236-1793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY10001433
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: