Provider Demographics
NPI:1366587511
Name:DEMOS, ELAINE VIRGINIA (EDD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:VIRGINIA
Last Name:DEMOS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:E
Other - Middle Name:VIRGINIA
Other - Last Name:DEMOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:PO BOX 1425
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01262
Mailing Address - Country:US
Mailing Address - Phone:413-931-5254
Mailing Address - Fax:413-298-4020
Practice Address - Street 1:25 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01262
Practice Address - Country:US
Practice Address - Phone:413-931-5254
Practice Address - Fax:413-298-4020
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2389103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEW02666OtherBCBS