Healthcare Provider Details

I. General information

NPI: 1366792202
Provider Name (Legal Business Name): METROWEST NEUROPSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W PARK DR SUITE 280
WESTBOROUGH MA
01581-3942
US

IV. Provider business mailing address

1900 W PARK DR SUITE 280
WESTBOROUGH MA
01581-3942
US

V. Phone/Fax

Practice location:
  • Phone: 508-983-1425
  • Fax: 508-983-0987
Mailing address:
  • Phone: 508-983-1425
  • Fax: 508-983-0987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY J GAINES
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 508-983-1425