Healthcare Provider Details

I. General information

NPI: 1598310575
Provider Name (Legal Business Name): ELLEN A DOERNBERG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 OAK ST STE G-10
NEWTON MA
02464-1492
US

IV. Provider business mailing address

340 TURNPIKE ST STE 1-3A
CANTON MA
02021-2700
US

V. Phone/Fax

Practice location:
  • Phone: 617-658-5600
  • Fax:
Mailing address:
  • Phone: 781-619-1500
  • Fax: 781-619-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY10001930
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: