Healthcare Provider Details

I. General information

NPI: 1790410967
Provider Name (Legal Business Name): COLLABORATIVE CHILD NEUROPSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 A ST
BURLINGTON MA
01803-3412
US

IV. Provider business mailing address

17 EMERSON PL
NEEDHAM MA
02492-2828
US

V. Phone/Fax

Practice location:
  • Phone: 781-708-3374
  • Fax:
Mailing address:
  • Phone: 781-708-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: EVA JANSIEWICZ
Title or Position: OWNER
Credential: PH.D.
Phone: 781-708-3374