Provider Demographics
NPI:1104846476
Name:ADVANCED NEUROTHERAPY, PC
Entity Type:Organization
Organization Name:ADVANCED NEUROTHERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-444-9115
Mailing Address - Street 1:10436 PARK TREE PL
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4487
Mailing Address - Country:US
Mailing Address - Phone:781-444-9115
Mailing Address - Fax:
Practice Address - Street 1:140 BRISTOL RD
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2730
Practice Address - Country:US
Practice Address - Phone:781-444-9115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3976103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA722869OtherTUFTS COMMERCIAL
MAW03950OtherBCBS PROVIDER #
MAW03950OtherNATIONAL HERITAGE
MAW03950OtherBCBS PROVIDER #
MA199652295546OtherHUMANA