Healthcare Provider Details

I. General information

NPI: 1083927768
Provider Name (Legal Business Name): VINCENZO GIANCARLO TERAN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

IV. Provider business mailing address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-1183
  • Fax: 617-232-1280
Mailing address:
  • Phone: 617-665-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10047
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: