Healthcare Provider Details

I. General information

NPI: 1023284460
Provider Name (Legal Business Name): MARY PANTUHOVA, PSY.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 WYMAN ST
WABAN MA
02468-1529
US

IV. Provider business mailing address

91 WYMAN ST
WABAN MA
02468-1529
US

V. Phone/Fax

Practice location:
  • Phone: 617-332-7596
  • Fax:
Mailing address:
  • Phone: 617-332-7596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6733
License Number StateMA

VIII. Authorized Official

Name: DR. MARY KNORRING PANTUHOVA
Title or Position: DIRECTOR
Credential: PSY.D.
Phone: 617-332-7596