Provider Demographics
NPI:1265652804
Name:SPEISER, PHILLIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:SPEISER
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 1:15 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2403
Mailing Address - Country:US
Mailing Address - Phone:617-524-3904
Mailing Address - Fax:
Practice Address - Street 1:1125 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2178
Practice Address - Country:US
Practice Address - Phone:617-989-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA672101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA672OtherLMHC LICENSE NUMBER