Basic Information
| Provider Information | |||||||||
| NPI: | 1255466074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROTEAU POLAK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.I.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROTEAU | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | JA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WEST BOYLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015831670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088536221 | ||||||||
| FaxNumber: | 5088354859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 114669 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.