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General NPI Number Information
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NPI Number | 1124227905
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Entity Type | Organization
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Legal Business Name | PSYCHMATRIX FOR CHILD & ADOLESCENT PSYCHIATRY, LLC
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Dates
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Enumeration Date | 07/12/2007
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Last Update Date | 07/12/2007
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Provider Practice Location Address
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Address Line | 35 POST OFFICE PARK STE 3505
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City | WILBRAHAM
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State | MA
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Zip | 01095-1186
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Country | US
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Telephone | 413-596-4601
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Fax | 413-596-4609
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Provider Business Mailing Address
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Address Line | 12 RUTH DR
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City | WILBRAHAM
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State | MA
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Zip | 01095-2610
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Country | US
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Telephone | 413-596-4601
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Fax | 413-596-4609
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN CARY
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Credential | MD
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Telephone | 413-596-4601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 73294
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License Number State | MA
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