Provider Demographics
NPI:1629590443
Name:WINER, JEFFREY PHILLIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PHILLIP
Last Name:WINER
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 1:57 BEDFORD ST STE 230
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4502
Mailing Address - Country:US
Mailing Address - Phone:339-970-8573
Mailing Address - Fax:
Practice Address - Street 1:57 BEDFORD ST STE 230
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420
Practice Address - Country:US
Practice Address - Phone:339-970-8573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA10965103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program