Provider Demographics
NPI:1083099097
Name:AVITABILE, CAROLINE (PSYD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:AVITABILE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1972
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:
Practice Address - Street 1:12 ALFRED ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1972
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MA10534103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program