Healthcare Provider Details

I. General information

NPI: 1578670881
Provider Name (Legal Business Name): BALDPATE PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 BALDPATE RD
GEORGETOWN MA
01833
US

IV. Provider business mailing address

83 BALDPATE RD
GEORGETOWN MA
01833
US

V. Phone/Fax

Practice location:
  • Phone: 978-352-2131
  • Fax:
Mailing address:
  • Phone: 978-352-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierBAM12617
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS
# 2
Identifier104892
Identifier TypeOTHER
Identifier State
Identifier IssuerMAGELLAN
# 3
Identifier1899473
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: CYNTHIA A HATHAWAY
Title or Position: ASSISTANT OFFICE MANAGER
Credential:
Phone: 978-352-2131