Healthcare Provider Details

I. General information

NPI: 1851814917
Provider Name (Legal Business Name): PAX ET BONUM PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CONCORD AVE
CAMBRIDGE MA
02138-2322
US

IV. Provider business mailing address

93 OXFORD ST # 2
ARLINGTON MA
02474-6907
US

V. Phone/Fax

Practice location:
  • Phone: 617-515-9902
  • Fax:
Mailing address:
  • Phone: 617-515-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number10310
License Number StateMA

VIII. Authorized Official

Name: DR. KRISTEN K ELLARD
Title or Position: PSYCHOLOGIST/SOLE MEMBER
Credential: PH.D.
Phone: 617-515-9902