Healthcare Provider Details

I. General information

NPI: 1932209756
Provider Name (Legal Business Name): GRACE JOHANNETTE MUSHRUSH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

940 BELMONT ST
BROCKTON MA
02301-5596
US

V. Phone/Fax

Practice location:
  • Phone: 617-244-7589
  • Fax: 617-965-4142
Mailing address:
  • Phone: 508-583-4500
  • Fax: 774-826-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35147
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number35147
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number35147
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35147
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: