Provider Demographics
NPI:1598789638
Name:PARADISE, DAVID M (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:PARADISE
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 1:10 LANGLEY RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1917
Mailing Address - Country:US
Mailing Address - Phone:617-332-6690
Mailing Address - Fax:617-558-1206
Practice Address - Street 1:10 LANGLEY RD
Practice Address - Street 2:SUITE 401
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-1917
Practice Address - Country:US
Practice Address - Phone:617-332-6690
Practice Address - Fax:617-558-1206
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10002461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO4708OtherMASSBLUECROSS BLUE SHIELD
MAP21327Medicare ID - Type Unspecified