Provider Demographics
NPI:1346720646
Name:MEDICAL COMMUNITY PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:MEDICAL COMMUNITY PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:OLUSOLA
Authorized Official - Last Name:AKINKUOYE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, DNP
Authorized Official - Phone:508-733-5951
Mailing Address - Street 1:264 UNION AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6348
Mailing Address - Country:US
Mailing Address - Phone:774-244-4128
Mailing Address - Fax:774-244-4129
Practice Address - Street 1:264 UNION AVE APT 2
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6348
Practice Address - Country:US
Practice Address - Phone:508-733-5951
Practice Address - Fax:508-321-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233605163WP0808X
163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1366796088OtherCOMMONWEALTH CARE ALLIANCE
MA110110469AMedicaid
MA1366796088OtherBLUE CROSS BLUE SHIELD