Healthcare Provider Details

I. General information

NPI: 1235434804
Provider Name (Legal Business Name): PROFESSIONAL PROFILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 SANTUIT NEWTOWN RD
COTUIT MA
02635-2509
US

IV. Provider business mailing address

1860 SANTUIT NEWTOWN RD
COTUIT MA
02635-2509
US

V. Phone/Fax

Practice location:
  • Phone: 508-548-8989
  • Fax: 508-548-5789
Mailing address:
  • Phone: 508-548-8989
  • Fax: 508-548-5789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GERALD P ELOVITZ
Title or Position: GENERAL PARTNER
Credential: ED.D.
Phone: 508-548-8989