Provider Demographics
NPI:1932124344
Name:VACCA, DOROTHY MARY (EDD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:MARY
Last Name:VACCA
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 RAFFAELE DR
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-0313
Mailing Address - Country:US
Mailing Address - Phone:781-899-2091
Mailing Address - Fax:781-899-2091
Practice Address - Street 1:98 RAFFAELE DR
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-0313
Practice Address - Country:US
Practice Address - Phone:781-899-2091
Practice Address - Fax:781-899-2091
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4377103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWO4261OtherBLUE CROSS BLUE SHIELD PR
MIWO4261OtherBLUE CROSS BLUE SHIELD PR