Provider Demographics
NPI:1386712636
Name:FREEMAN YOUNG, ELIZABETH (EDD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FREEMAN YOUNG
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1814
Mailing Address - Country:US
Mailing Address - Phone:617-953-9285
Mailing Address - Fax:
Practice Address - Street 1:840 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1433
Practice Address - Country:US
Practice Address - Phone:781-890-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4216103T00000X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAYO W51406Medicare ID - Type Unspecified