Healthcare Provider Details

I. General information

NPI: 1386710929
Provider Name (Legal Business Name): MARYANN A PINGALORE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 BOSTON AVE SUITE 2500
MEDFORD MA
02155
US

IV. Provider business mailing address

21 CRESCENT ST
NATICK MA
01760
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-3856
  • Fax: 508-651-0830
Mailing address:
  • Phone: 508-653-1489
  • Fax: 508-651-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3269
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: