Provider Demographics
NPI:1578619201
Name:BLACK, BRENDA POLLARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:POLLARA
Last Name:BLACK
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 1:12 WHITCOMB AVE
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-3385
Mailing Address - Country:US
Mailing Address - Phone:781-740-1128
Mailing Address - Fax:781-740-1320
Practice Address - Street 1:12 WHITCOMB AVE
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-3385
Practice Address - Country:US
Practice Address - Phone:781-740-1128
Practice Address - Fax:781-740-1320
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical