Provider Demographics
NPI:1437299955
Name:BURDETTE, NELLY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NELLY
Middle Name:E
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NELLY
Other - Middle Name:
Other - Last Name:FREYDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5425
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01093103TH0004X
MA8669103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth