Provider Demographics
NPI:1336291004
Name:KNOWLTON, STEPHEN R (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:KNOWLTON
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 1:466 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2721
Mailing Address - Country:US
Mailing Address - Phone:617-859-5806
Mailing Address - Fax:
Practice Address - Street 1:466 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 201B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2721
Practice Address - Country:US
Practice Address - Phone:617-859-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6510103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical