MEDICARE: MS. ELISABETH ELLIS WAINGROW MSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	104093	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01953	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1811045537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELISABETH ELLIS WAINGROW MSW, LICSW

Provider Business Mailing Address
First Line	:	P.O. BOX 610094
Second Line	:
City	:	NEWTON HIGHLANDS
State	:	MA
Zip	:	02461-0094
Country	:	US
Telephone Number	:	617-244-8132
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 LINCOLN ST
Second Line	:
City	:	NEWTON HIGHLANDS
State	:	MA
Zip	:	02461-1524
Country	:	US
Telephone Number	:	617-244-8132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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