Healthcare Provider Details

I. General information

NPI: 1922212810
Provider Name (Legal Business Name): OMAR GAMAL REID PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: OMAR GAMAL REID PSY.D

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 BLUE HILL AVENUE 1960 WASHINGTON STREET, ROXBURY, MA 02119
BOSTON MA
02124
US

IV. Provider business mailing address

PO BOX 190781
BOSTON MA
02119-0015
US

V. Phone/Fax

Practice location:
  • Phone: 617-822-0829
  • Fax: 617-825-7804
Mailing address:
  • Phone: 617-230-6158
  • Fax: 617-825-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1209
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number456
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: