Healthcare Provider Details

I. General information

NPI: 1356933014
Provider Name (Legal Business Name): ANITA J AVAKIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ADMINISTRATION RD # 2324
BRIDGEWATER MA
02324-3230
US

IV. Provider business mailing address

74 CANNON FORGE DR # 2035
FOXBOROUGH MA
02035-5217
US

V. Phone/Fax

Practice location:
  • Phone: 508-279-4500
  • Fax:
Mailing address:
  • Phone: 317-294-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10828
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: