Healthcare Provider Details

I. General information

NPI: 1407048432
Provider Name (Legal Business Name): BOSTON NEUROPSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 HIGHLAND AVENUE 2ND FLOOR
NEEDHAM MA
02494
US

IV. Provider business mailing address

687 HIGHLAND AVENUE 2ND FLOOR
NEEDHAM MA
02494-2409
US

V. Phone/Fax

Practice location:
  • Phone: 781-559-8444
  • Fax: 781-559-8117
Mailing address:
  • Phone: 781-559-8444
  • Fax: 781-559-8117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN A DOMINGOS
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 781-559-8444