Healthcare Provider Details

I. General information

NPI: 1467949636
Provider Name (Legal Business Name): GLMPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 DEVONSHIRE ST STE 503
BOSTON MA
02110-1415
US

IV. Provider business mailing address

185 DEVONSHIRE ST STE 503
BOSTON MA
02110-1415
US

V. Phone/Fax

Practice location:
  • Phone: 617-841-7272
  • Fax:
Mailing address:
  • Phone: 617-841-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number10337
License Number StateMA

VIII. Authorized Official

Name: TOMASZ VAV
Title or Position: BILLING MANAGER
Credential:
Phone: 617-435-0202