Provider Demographics
NPI:1083772537
Name:CLIONSKY, MITCHELL I (PHD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:I
Last Name:CLIONSKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MAPLE STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1828
Mailing Address - Country:US
Mailing Address - Phone:413-734-3331
Mailing Address - Fax:413-739-1652
Practice Address - Street 1:155 MAPLE STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1828
Practice Address - Country:US
Practice Address - Phone:413-734-3331
Practice Address - Fax:413-739-1652
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2113103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11365OtherHEALTH NEW ENGLAND
5024760OtherCHAMPUS
734079OtherTUFTS
W02301OtherBCBS OF MA
11365OtherHEALTH NEW ENGLAND