Healthcare Provider Details

I. General information

NPI: 1063039121
Provider Name (Legal Business Name): MARIA A NEIZVESTNAYA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRIMARY CARE BEHAVIORAL HEALTH FITCHBURG FAMILY MEDICINE
FITCHBURG MA
01420
US

IV. Provider business mailing address

PRIMARY CARE BEHAVIORAL HEALTH FITCHBURG FAMILY MEDICINE
FITCHBURG MA
01420
US

V. Phone/Fax

Practice location:
  • Phone: 978-343-5270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY10000776
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: