Provider Demographics
NPI:1639364151
Name:GUPTA, KOMAL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KOMAL
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 HIGHLAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2141
Practice Address - Country:US
Practice Address - Phone:978-354-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9678103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA003388301OtherMEDICARE