1225211436 NPI number — ELIZABETH TALEAS SOUTHALL LICSW

Table of content: ELIZABETH TALEAS SOUTHALL LICSW (NPI 1225211436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225211436 NPI number — ELIZABETH TALEAS SOUTHALL LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHALL
Provider First Name:
ELIZABETH
Provider Middle Name:
TALEAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225211436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 934
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02339-0934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-552-5124
Provider Business Mailing Address Fax Number:
888-317-2641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 WASHINGTON ST STE 603
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANOVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02339-2476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-306-2748
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  212052 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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