Healthcare Provider Details

I. General information

NPI: 1265469282
Provider Name (Legal Business Name): KENNETH I WEISS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MAIN ST SUITE 2D
NORTH EASTON MA
02356-1468
US

IV. Provider business mailing address

115 MAIN STREET SUITE 2D
NORTH EASTON MA
02356-1443
US

V. Phone/Fax

Practice location:
  • Phone: 508-238-7766
  • Fax: 508-230-5089
Mailing address:
  • Phone: 508-238-7766
  • Fax: 508-230-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3881
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number3881
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number3881
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: