Healthcare Provider Details

I. General information

NPI: 1184665192
Provider Name (Legal Business Name): MARTIELE ELLIOTT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 OLD NORTH RD
WORTHINGTON MA
01098
US

IV. Provider business mailing address

PO BOX 154
GT BARRINGTON MA
01230
US

V. Phone/Fax

Practice location:
  • Phone: 413-238-5511
  • Fax: 413-238-5358
Mailing address:
  • Phone: 413-717-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111075
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: