Provider Demographics
NPI:1033221601
Name:RUPERT, DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:RUPERT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 BAY STATE RD
Mailing Address - Street 2:C/O DANIELSEN INSTITUTE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1506
Mailing Address - Country:US
Mailing Address - Phone:978-689-5392
Mailing Address - Fax:617-353-5539
Practice Address - Street 1:204 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4721
Practice Address - Country:US
Practice Address - Phone:978-689-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7929103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARU-W51515Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER