Healthcare Provider Details

I. General information

NPI: 1891997615
Provider Name (Legal Business Name): MARY E. BROLLY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 WASHINGTON ST
BRAINTREE MA
02184-5434
US

IV. Provider business mailing address

985 WASHINGTON ST
BRAINTREE MA
02184-5434
US

V. Phone/Fax

Practice location:
  • Phone: 781-519-9715
  • Fax: 508-580-4404
Mailing address:
  • Phone: 781-519-9715
  • Fax: 508-580-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9836
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: