Provider Demographics
NPI:1447359849
Name:LITWACK, STEPHEN ELLIOT (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ELLIOT
Last Name:LITWACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 BELMONT STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02401
Mailing Address - Country:US
Mailing Address - Phone:508-895-9393
Mailing Address - Fax:
Practice Address - Street 1:1342 BELMONT STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02401
Practice Address - Country:US
Practice Address - Phone:508-895-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPY2105PR103T00000X
MA202103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
161283OtherMAGELLAN
W02296OtherBCBS
W02296Medicare ID - Type Unspecified