Healthcare Provider Details

I. General information

NPI: 1932509882
Provider Name (Legal Business Name): BENJAMIN COOLEY HALL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 11/13/2023
Certification Date: 11/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 ADMINISTRATION RD
BRIDGEWATER MA
02324-3230
US

IV. Provider business mailing address

20 ADMINISTRATION RD
BRIDGEWATER MA
02324-3230
US

V. Phone/Fax

Practice location:
  • Phone: 508-279-4577
  • Fax:
Mailing address:
  • Phone: 978-434-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01650
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPS01650
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number10630
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: