Healthcare Provider Details

I. General information

NPI: 1164664157
Provider Name (Legal Business Name): AUTUMN LYNN PORUBSKY PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CAREW STREET STE 2
SPRINGFIELD MA
01104-2146
US

IV. Provider business mailing address

280 CHESTNUT ST FL 2
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-9816
  • Fax: 413-794-4945
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11002
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: