Healthcare Provider Details

I. General information

NPI: 1689103681
Provider Name (Legal Business Name): PAUL ANTHONY EZZY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PAUL ANTHONY ELIAS EZZY

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MECHANIC ST STE 206
NEWTON UPPER FALLS MA
02464-1472
US

IV. Provider business mailing address

64 LEIGHTON ST
BANGOR ME
04401-3851
US

V. Phone/Fax

Practice location:
  • Phone: 339-204-4330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC6997
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11570
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: