Healthcare Provider Details

I. General information

NPI: 1609997667
Provider Name (Legal Business Name): SQUARE PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 WATERTOWN ST
WATERTOWN MA
02472-2576
US

IV. Provider business mailing address

124 WATERTOWN ST
WATERTOWN MA
02472-2576
US

V. Phone/Fax

Practice location:
  • Phone: 617-926-8200
  • Fax:
Mailing address:
  • Phone: 617-926-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1023920
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number43500
License Number StateMA

VIII. Authorized Official

Name: DR. BRIAN JOHNSON
Title or Position: OWNER
Credential: M.D.
Phone: 617-926-8300