Healthcare Provider Details

I. General information

NPI: 1407932270
Provider Name (Legal Business Name): MIRI ELANA SKOLNIK PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRI ELANA SKOLNIK PSY.D.

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WILLARD ST
QUINCY MA
02169-7482
US

IV. Provider business mailing address

76 CAROLINA AVE APT.1
JAMAICA PLAIN MA
02130-3205
US

V. Phone/Fax

Practice location:
  • Phone: 617-774-1074
  • Fax:
Mailing address:
  • Phone: 617-971-0432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7868
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: