Healthcare Provider Details

I. General information

NPI: 1093483265
Provider Name (Legal Business Name): REBECCA FORTGANG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 CAMBRIDGE ST
BOSTON MA
02114-2790
US

IV. Provider business mailing address

185 CAMBRIDGE ST
BOSTON MA
02114-2790
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY5000221
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: