Provider Demographics
NPI:1689103681
Name:EZZY, PAUL ANTHONY (MA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:EZZY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:ANTHONY ELIAS
Other - Last Name:EZZY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:64 LEIGHTON ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 MECHANIC ST STE 206
Practice Address - Street 2:
Practice Address - City:NEWTON UPPER FALLS
Practice Address - State:MA
Practice Address - Zip Code:02464-1472
Practice Address - Country:US
Practice Address - Phone:339-204-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MECC6997101YP2500X
MA11570101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional