Provider Demographics
NPI:1366011819
Name:DEJESUS, ELISHA (LCSW)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DWIGHT RD STE 105-109
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1576
Mailing Address - Country:US
Mailing Address - Phone:860-461-7792
Mailing Address - Fax:508-433-1871
Practice Address - Street 1:175 DWIGHT RD STE 105-109
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1576
Practice Address - Country:US
Practice Address - Phone:860-461-7792
Practice Address - Fax:508-433-1871
Is Sole Proprietor?:No
Enumeration Date:2021-06-20
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2260451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical