Provider Demographics
NPI:1265469282
Name:WEISS, KENNETH I (PSYD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:WEISS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MAIN STREET
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1443
Mailing Address - Country:US
Mailing Address - Phone:508-238-7766
Mailing Address - Fax:508-230-5089
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1468
Practice Address - Country:US
Practice Address - Phone:508-238-7766
Practice Address - Fax:508-230-5089
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3881103TC0700X, 261QV0200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA773102OtherTUFTS HEALTH PLAN
MA1899031Medicaid
MAWO3901OtherBC BS OF MASSACHUSETTS
MAWO3901OtherBC BS OF MASSACHUSETTS