Healthcare Provider Details

I. General information

NPI: 1942497565
Provider Name (Legal Business Name): MICHELE CANDRIAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL STREET, MCLEAN HOSPITAL NORTH BELKNAP 1
BELMONT MA
02428
US

IV. Provider business mailing address

55 FRUIT STREET MASSACHUSETTS GENERAL HOSPITAL
BOSTON MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2933
  • Fax:
Mailing address:
  • Phone: 617-726-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9473
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: