Healthcare Provider Details

I. General information

NPI: 1003711078
Provider Name (Legal Business Name): NORTHERN NEUROPSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MAIN ST STE 17A
WINCHESTER MA
01890-2940
US

IV. Provider business mailing address

540 MAIN ST STE 17A
WINCHESTER MA
01890-2940
US

V. Phone/Fax

Practice location:
  • Phone: 781-710-6105
  • Fax: 617-231-9581
Mailing address:
  • Phone: 781-710-6105
  • Fax: 617-231-9581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. NICOLE KASSISSIEH
Title or Position: OWNER/FOUNDER
Credential: PSYD
Phone: 781-710-6105