Provider Demographics
NPI:1063566339
Name:DAN, ELISHEVA (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISHEVA
Middle Name:
Last Name:DAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BEACON ST
Mailing Address - Street 2:SUITE #304
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4816
Mailing Address - Country:US
Mailing Address - Phone:617-738-0780
Mailing Address - Fax:617-566-9314
Practice Address - Street 1:1415 BEACON ST
Practice Address - Street 2:SUITE #304
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4816
Practice Address - Country:US
Practice Address - Phone:617-738-0780
Practice Address - Fax:617-566-9314
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7240103TC0700X
MA696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1893Medicare PIN
MAW50883Medicare PIN