Healthcare Provider Details

I. General information

NPI: 1932124344
Provider Name (Legal Business Name): DOROTHY MARY VACCA ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 RAFFAELE DR
WALTHAM MA
02452-0313
US

IV. Provider business mailing address

98 RAFFAELE DR
WALTHAM MA
02452-0313
US

V. Phone/Fax

Practice location:
  • Phone: 781-899-2091
  • Fax: 781-899-2091
Mailing address:
  • Phone: 781-899-2091
  • Fax: 781-899-2091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4377
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: