Healthcare Provider Details

I. General information

NPI: 1942944095
Provider Name (Legal Business Name): ERICA GWEN DEBARTOLO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FOXBOROUGH BLVD STE 230
FOXBOROUGH MA
02035-2974
US

IV. Provider business mailing address

1968 CENTRAL AVE
NEEDHAM MA
02492-1410
US

V. Phone/Fax

Practice location:
  • Phone: 508-425-5883
  • Fax:
Mailing address:
  • Phone: 774-567-3682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: