Healthcare Provider Details

I. General information

NPI: 1467545798
Provider Name (Legal Business Name): SANFORD MARVIN PORTNOY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 HELENE RD
WABAN MA
02468-1024
US

IV. Provider business mailing address

35 HELENE RD
WABAN MA
02468-1024
US

V. Phone/Fax

Practice location:
  • Phone: 617-965-2147
  • Fax: 617-527-3538
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number278
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: