Provider Demographics
NPI:1942397914
Name:FENNELL, LOUISE CP (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:CP
Last Name:FENNELL
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 1:8 CEDAR ST STE 43
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-6362
Mailing Address - Country:US
Mailing Address - Phone:781-538-5193
Mailing Address - Fax:
Practice Address - Street 1:8 CEDAR ST STE 43
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6362
Practice Address - Country:US
Practice Address - Phone:781-538-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-877103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI2356137OtherUHA
HI0000250936OtherHMSA
HI56033501Medicaid
HI2356137OtherUHA