Healthcare Provider Details

I. General information

NPI: 1285871772
Provider Name (Legal Business Name): MITCHELL I. CLIONSKY, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MAPLE ST SUITE 203
SPRINGFIELD MA
01105-1828
US

IV. Provider business mailing address

155 MAPLE ST 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: MS. REBEKAH L MAYOU
Title or Position: OFFICE MANAGER
Credential:
Phone: 413-734-3331