Provider Demographics
NPI:1760544688
Name:TITLE, JEFFREY JOSHUA (EDD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSHUA
Last Name:TITLE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 MAIN ST
Mailing Address - Street 2:SUITE NUMBER 5
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1822
Mailing Address - Country:US
Mailing Address - Phone:413-528-5155
Mailing Address - Fax:
Practice Address - Street 1:491 MAIN ST
Practice Address - Street 2:SUITE NUMBER 5
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1822
Practice Address - Country:US
Practice Address - Phone:413-528-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA873103T00000X
NH611103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01561Medicare ID - Type Unspecified
MANH2210Medicare ID - Type Unspecified