Provider Demographics
NPI:1497701197
Name:PANTUHOVA, MARY KNORRING (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KNORRING
Last Name:PANTUHOVA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:PANTUHOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:91 WYMAN ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1529
Mailing Address - Country:US
Mailing Address - Phone:617-332-7596
Mailing Address - Fax:617-663-6135
Practice Address - Street 1:91 WYMAN ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-1529
Practice Address - Country:US
Practice Address - Phone:617-332-7596
Practice Address - Fax:617-663-6135
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6733103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW40013OtherMEDICARE
MA1497701197OtherNPI