Healthcare Provider Details

I. General information

NPI: 1083772537
Provider Name (Legal Business Name): MITCHELL I CLIONSKY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MAPLE STREET SUITE 203
SPRINGFIELD MA
01105-1828
US

IV. Provider business mailing address

155 MAPLE STREET SUITE 203
SPRINGFIELD MA
01105-1828
US

V. Phone/Fax

Practice location:
  • Phone: 413-734-3331
  • Fax: 413-739-1652
Mailing address:
  • Phone: 413-734-3331
  • Fax: 413-739-1652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2113
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: