Healthcare Provider Details

I. General information

NPI: 1982034211
Provider Name (Legal Business Name): AVY A SKOLNIK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SPRINGS RD
BEDFORD MA
01730-1114
US

IV. Provider business mailing address

200 SPRINGS RD 152
BEDFORD MA
01730-1114
US

V. Phone/Fax

Practice location:
  • Phone: 781-687-3532
  • Fax:
Mailing address:
  • Phone: 781-687-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY 10225 PR
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: