Healthcare Provider Details

I. General information

NPI: 1619425030
Provider Name (Legal Business Name): GERALD MICHAEL REID PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 NEWBURY ST FL 5
BOSTON MA
02115-2738
US

IV. Provider business mailing address

361 NEWBURY ST FL 5
BOSTON MA
02115-2738
US

V. Phone/Fax

Practice location:
  • Phone: 857-352-2037
  • Fax:
Mailing address:
  • Phone: 857-352-2037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number10916
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: