Provider Demographics
NPI:1770822173
Name:PAMELA FANTINI PHD LLC
Entity Type:Organization
Organization Name:PAMELA FANTINI PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTINI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-367-5374
Mailing Address - Street 1:7 MILL POND
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2686
Mailing Address - Country:US
Mailing Address - Phone:781-367-5374
Mailing Address - Fax:978-745-5455
Practice Address - Street 1:7 MILL POND
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2686
Practice Address - Country:US
Practice Address - Phone:781-367-5374
Practice Address - Fax:978-745-5455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY 4599251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFA W04460Medicare PIN