Healthcare Provider Details

I. General information

NPI: 1568638435
Provider Name (Legal Business Name): ROBERT M TRUDEL SCD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 STAGECOACH RD
LEOMINSTER MA
01453-3472
US

IV. Provider business mailing address

14 STAGECOACH RD
LEOMINSTER MA
01453-3472
US

V. Phone/Fax

Practice location:
  • Phone: 978-537-4920
  • Fax:
Mailing address:
  • Phone: 978-537-4920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2277
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2277
License Number StateMA

VIII. Authorized Official

Name: DR. ROBERT MICHAEL TRUDEL
Title or Position: PRESIDENT
Credential:
Phone: 978-537-4920