Healthcare Provider Details

I. General information

NPI: 1639398779
Provider Name (Legal Business Name): NANCY E ROOSA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SAGAMORE AVE
MEDFORD MA
02155-2145
US

IV. Provider business mailing address

124 SAGAMORE AVE
MEDFORD MA
02155-2145
US

V. Phone/Fax

Practice location:
  • Phone: 781-710-1881
  • Fax:
Mailing address:
  • Phone: 781-710-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number8421
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: