MEDICARE: DR. WILLIAM DERRY HEASLEY PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	7033	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W05600	OTHER	MA	CLINICAL PSYCHOLOGIST

General Provider Information

NPI Number	:	1588728513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM DERRY HEASLEY PSY.D.

Provider Business Mailing Address
First Line	:	85 EASTERN AVE
Second Line	:	SUITE 108
City	:	GLOUCESTER
State	:	MA
Zip	:	01930-1869
Country	:	US
Telephone Number	:	978-282-8281
Fax Number	:	978-282-1143

Provider Business Practice Location Address
First Line	:	85 EASTERN AVE
Second Line	:	SUITE 108
City	:	GLOUCESTER
State	:	MA
Zip	:	01930-1869
Country	:	US
Telephone Number	:	978-282-8281
Fax Number	:	978-282-1143

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	06/20/2013

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