Healthcare Provider Details

I. General information

NPI: 1245678515
Provider Name (Legal Business Name): MR. JOSHUA CUDDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CENTRAL ST
WALTHAM MA
02453-5465
US

IV. Provider business mailing address

118 CENTRAL ST
WALTHAM MA
02453-5465
US

V. Phone/Fax

Practice location:
  • Phone: 781-891-0555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: