Provider Demographics
NPI:1427029297
Name:NEWTON-WELLESLEY PSYCHIATRY
Entity Type:Organization
Organization Name:NEWTON-WELLESLEY PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-332-2047
Mailing Address - Street 1:2364 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1440
Mailing Address - Country:US
Mailing Address - Phone:617-332-2047
Mailing Address - Fax:617-332-7341
Practice Address - Street 1:40 WALNUT ST STE 302
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2175
Practice Address - Country:US
Practice Address - Phone:617-332-2047
Practice Address - Fax:617-332-7341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TC0700X, 1041C0700X, 163WP0808X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9756981Medicaid
MAM14702OtherBLUE CROSS BLUE SHIELD
MAM14702Medicare PIN