Provider Demographics
NPI:1558380360
Name:MINER, JOHN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MINER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PORTSMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1411
Mailing Address - Country:US
Mailing Address - Phone:617-782-0303
Mailing Address - Fax:
Practice Address - Street 1:100 ELIOT ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1435
Practice Address - Country:US
Practice Address - Phone:617-782-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4462103G00000X, 103TA0700X, 103TC0700X, 103TC2200X
MA166523103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0495668OtherUNITED BEHAVIORAL HEALTH
MA13632OtherHANCOCK
MA732087OtherTUFTS HEALTH CARE
MA0518255Medicaid
MA7764376OtherAETNA
MA7764376OtherAETNA
MA732087OtherTUFTS HEALTH CARE