Healthcare Provider Details

I. General information

NPI: 1902528565
Provider Name (Legal Business Name): CEREBELLA: THE PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 3RD ST STE 510
SAN FRANCISCO CA
94107-6803
US

IV. Provider business mailing address

588 BOSTON POST RD STE 325
WESTON MA
02493-1535
US

V. Phone/Fax

Practice location:
  • Phone: 617-209-9707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL S. BARRON
Title or Position: PHYSICIAN
Credential: MD PHD
Phone: 617-209-9707