Healthcare Provider Details

I. General information

NPI: 1851935860
Provider Name (Legal Business Name): PAUL DOMIGAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MORAN RD
NORTH BILLERICA MA
01862-3004
US

IV. Provider business mailing address

19 MORAN RD
NORTH BILLERICA MA
01862-3004
US

V. Phone/Fax

Practice location:
  • Phone: 339-222-8080
  • Fax:
Mailing address:
  • Phone: 339-222-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6857
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: