Provider Demographics
NPI:1750458170
Name:BROMBERG, JONAS IAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JONAS
Middle Name:IAN
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CHAPEL PL
Mailing Address - Street 2:HUMAN RELATIONS SERVICE
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-3130
Mailing Address - Country:US
Mailing Address - Phone:781-235-4950
Mailing Address - Fax:781-235-7170
Practice Address - Street 1:11 CHAPEL PL
Practice Address - Street 2:HUMAN RELATIONS SERVICE
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-3130
Practice Address - Country:US
Practice Address - Phone:781-235-4950
Practice Address - Fax:781-235-7170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7257103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral