Provider Demographics
NPI:1396012373
Name:DENIETOLIS, BRIAN M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:DENIETOLIS
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 1:411 VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1736
Mailing Address - Country:US
Mailing Address - Phone:508-843-5009
Mailing Address - Fax:
Practice Address - Street 1:305 BELMONT ST
Practice Address - Street 2:UMASS ADOLESCENT CONTINUING CARE UNIT
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1681
Practice Address - Country:US
Practice Address - Phone:508-368-3756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9444103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical