Provider Demographics
NPI:1558310631
Name:GAVIGAN, CARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARIE
Middle Name:
Last Name:GAVIGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 MARLBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2020
Mailing Address - Country:US
Mailing Address - Phone:617-247-3457
Mailing Address - Fax:
Practice Address - Street 1:82 MARLBOROUGH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2020
Practice Address - Country:US
Practice Address - Phone:617-247-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51112Medicare ID - Type Unspecified