Healthcare Provider Details

I. General information

NPI: 1548775190
Provider Name (Legal Business Name): NEURODEVELOPMENTAL EDUCATIONAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 EDGEHILL ROAD
BROOKLINE MA
02445
US

IV. Provider business mailing address

26 EDGEHILL RD
BROOKLINE MA
02445-7722
US

V. Phone/Fax

Practice location:
  • Phone: 617-777-1270
  • Fax: 617-307-4052
Mailing address:
  • Phone: 617-777-1270
  • Fax: 617-307-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7942
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113492
License Number StateMA

VIII. Authorized Official

Name: KATHERINE GAMBLE
Title or Position: PARTNER
Credential: PSY.D
Phone: 617-777-1270