Healthcare Provider Details

I. General information

NPI: 1679094023
Provider Name (Legal Business Name): ANTONIA VICTORIA SELIGOWSKI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST. MAIL STOP 212
BELMONT MA
02478
US

IV. Provider business mailing address

115 MILL ST. MAIL STOP 212
BELMONT MA
02478
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2945
  • Fax:
Mailing address:
  • Phone: 617-855-2945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10927
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: