=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477743854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER C ENTWISTLE PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2007
-----------------------------------------------------
Last Update Date | 07/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 PUDDING BROOK DR
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02359-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-826-7197
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 MATTAKEESETT ST
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02359-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-293-3427
-----------------------------------------------------
Fax | 781-826-7198
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 4237
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 4237
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------