Provider Demographics
NPI:1851382808
Name:SIRACUSA, ANTHONY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:J
Last Name:SIRACUSA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:J
Other - Last Name:SIRACUSA
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:167 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:LANESBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01237-9669
Mailing Address - Country:US
Mailing Address - Phone:413-458-9601
Mailing Address - Fax:
Practice Address - Street 1:167 BAILEY RD
Practice Address - Street 2:
Practice Address - City:LANESBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01237-9669
Practice Address - Country:US
Practice Address - Phone:413-458-9601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0518468Medicaid
MAW03523Medicare ID - Type Unspecified