Healthcare Provider Details

I. General information

NPI: 1689760407
Provider Name (Legal Business Name): DEANNA LOUISE MORI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 857-364-4121
  • Fax: 857-364-4408
Mailing address:
  • Phone: 857-364-4121
  • Fax: 857-364-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4865
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number4865
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: