Provider Demographics
NPI:1891740841
Name:OBOLENSKY, MICHAEL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:OBOLENSKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 WELBY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-1132
Mailing Address - Country:US
Mailing Address - Phone:508-998-1115
Mailing Address - Fax:508-998-1140
Practice Address - Street 1:13 WELBY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-1132
Practice Address - Country:US
Practice Address - Phone:508-998-1115
Practice Address - Fax:508-998-1140
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3973103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0500194Medicaid
MA0500194Medicaid