Provider Demographics
NPI:1235434804
Name:PROFESSIONAL PROFILES
Entity Type:Organization
Organization Name:PROFESSIONAL PROFILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:508-548-8989
Mailing Address - Street 1:1860 SANTUIT NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:COTUIT
Mailing Address - State:MA
Mailing Address - Zip Code:02635-2509
Mailing Address - Country:US
Mailing Address - Phone:508-548-8989
Mailing Address - Fax:508-548-5789
Practice Address - Street 1:1860 SANTUIT NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:COTUIT
Practice Address - State:MA
Practice Address - Zip Code:02635-2509
Practice Address - Country:US
Practice Address - Phone:508-548-8989
Practice Address - Fax:508-548-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty