Healthcare Provider Details

I. General information

NPI: 1750458170
Provider Name (Legal Business Name): JONAS IAN BROMBERG PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 LINDEN ST
WELLESLEY MA
02482-7900
US

IV. Provider business mailing address

77 ORIOLE ST
WEST ROXBURY MA
02132-2976
US

V. Phone/Fax

Practice location:
  • Phone: 617-780-7046
  • Fax: 617-780-7046
Mailing address:
  • Phone: 617-780-7046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7257
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number7257
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: