MEDICARE: MR. JONATHAN TRISTAN HIRSCHBERGER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	EL32460	NH
2	103TC0700X	Clinical Psychologist	PSY5000304	MA
3	101YM0800X	Mental Health Counselor
4	103TC0700X	Clinical Psychologist	4711	CT

General Provider Information

NPI Number	:	1083969471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN TRISTAN HIRSCHBERGER

Provider Business Mailing Address
First Line	:	13 BRASTOW AVE
Second Line	:
City	:	SOMERVILLE
State	:	MA
Zip	:	02143-1402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	237 HIGHLAND AVE
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02494-3036
Country	:	US
Telephone Number	:	781-424-0631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2012
Last Update Date	:	06/04/2026

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