Healthcare Provider Details

I. General information

NPI: 1245463736
Provider Name (Legal Business Name): ELIE ST. BRICE SR. MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 WARREN ST
ROXBURY MA
02119-1833
US

IV. Provider business mailing address

435 WARREN ST
ROXBURY MA
02119-1833
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-7400
  • Fax: 617-541-3797
Mailing address:
  • Phone: 617-442-7400
  • Fax: 617-541-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: