Healthcare Provider Details

I. General information

NPI: 1003011388
Provider Name (Legal Business Name): ICCD PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 TURNPIKE ST SUITE 11A
CANTON MA
02021-2700
US

IV. Provider business mailing address

340 TURNPIKE ST SUITE 11A
CANTON MA
02021-2700
US

V. Phone/Fax

Practice location:
  • Phone: 617-641-0900
  • Fax: 617-641-0930
Mailing address:
  • Phone: 617-641-0900
  • Fax: 617-641-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOSEPH MOLDOVER
Title or Position: CO DIRECTOR
Credential: PSY.D
Phone: 617-641-0900