Healthcare Provider Details

I. General information

NPI: 1639364151
Provider Name (Legal Business Name): KOMAL GUPTA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 HIGHLAND AVE 2ND FLOOR
SALEM MA
01970-2141
US

IV. Provider business mailing address

207 WASHINGTON ST
BROOKLINE MA
02445-6866
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-2705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9678
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: