Healthcare Provider Details

I. General information

NPI: 1063508372
Provider Name (Legal Business Name): CATHERINE BRAWN FORTIER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE VA BOSTON HEALTHCARE SYSTEM 182-JP
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE VA BOSTON HEALTHCARE SYSTEM 182-JP
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-4361
  • Fax: 857-364-4544
Mailing address:
  • Phone: 857-364-4361
  • Fax: 857-364-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number8253
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number8253
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: