Provider Demographics
NPI:1811006877
Name:DEFANT, MIRIAM ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:ANN
Last Name:DEFANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:MA
Mailing Address - Zip Code:01364-0437
Mailing Address - Country:US
Mailing Address - Phone:978-544-3330
Mailing Address - Fax:978-544-1899
Practice Address - Street 1:131 W MAIN ST STE 27
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:MA
Practice Address - Zip Code:01364-1151
Practice Address - Country:US
Practice Address - Phone:978-544-3330
Practice Address - Fax:978-544-1899
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6207103G00000X, 103T00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADE W04980OtherBLUE CROSS BLUE SHIELD
MA102900OtherMAGELLAN BEHAVIORAL HEALT
MA5503602OtherAETNA PPO
MA0502570Medicaid
MA726233OtherTUFTS HEALTH PLAN
MA093085OtherVALUEOPTIONS
MAW04980Medicare ID - Type Unspecified