=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508069758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN A RYABCHENKO PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 SPRINGS RD PSYCHOLOGY (116B)
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01730-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-275-7500
-----------------------------------------------------
Fax | 781-687-3146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 OLMSTEAD ST
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-522-9385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 8702
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------