Healthcare Provider Details

I. General information

NPI: 1760615702
Provider Name (Legal Business Name): EDWARD JOHN ZADRAVEC PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 E DEDHAM ST
BOSTON MA
02118-2315
US

IV. Provider business mailing address

72 E DEDHAM ST
BOSTON MA
02118-2315
US

V. Phone/Fax

Practice location:
  • Phone: 617-292-9200
  • Fax: 617-292-9272
Mailing address:
  • Phone: 617-292-9200
  • Fax: 617-292-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7516
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: