Provider Demographics
NPI:1528647666
Name:MILLER-GOTTBERG, ELENS B
Entity type:Individual
Prefix:
First Name:ELENS
Middle Name:B
Last Name:MILLER-GOTTBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ELENS
Other - Middle Name:B
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3057 ACUSHNET AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-3636
Mailing Address - Country:US
Mailing Address - Phone:508-742-1040
Mailing Address - Fax:
Practice Address - Street 1:3057 ACUSHNET AVE
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-3636
Practice Address - Country:US
Practice Address - Phone:508-742-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1093017550Medicaid