=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174604979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MORTON PAUL BIRNBAUM PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 BOSTON POST RD SUITE 34
-----------------------------------------------------
City | SUDBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01776-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-443-0480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 BREWSTER RD
-----------------------------------------------------
City | SUDBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01776-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 402
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number | 402
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------