Provider Demographics
NPI:1477743854
Name:ENTWISTLE, PETER C (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:ENTWISTLE
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 1:50 MATTAKEESETT ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-2531
Mailing Address - Country:US
Mailing Address - Phone:781-293-3427
Mailing Address - Fax:781-826-7198
Practice Address - Street 1:54 PUDDING BROOK DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-2008
Practice Address - Country:US
Practice Address - Phone:781-826-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4237103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO4515OtherBLUE CROSS-BLUE SHIELD