Provider Demographics
NPI:1083687792
Name:POMERANTZ, MITCHELL ALLEN
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALLEN
Last Name:POMERANTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KENT ST # 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7901
Mailing Address - Country:US
Mailing Address - Phone:617-277-8107
Mailing Address - Fax:
Practice Address - Street 1:11 KENT ST # 2
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7901
Practice Address - Country:US
Practice Address - Phone:617-277-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-12
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8198103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW10533OtherBLUE CROSS/BLUE SHIELD
MAW51266Medicare UPIN