Provider Demographics
NPI: | 1962447714 |
---|---|
Name: | WALBRIDGE, MARIE MARGARET (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARIE |
Middle Name: | MARGARET |
Last Name: | WALBRIDGE |
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: | 61 CHAUNCY ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH WEYMOUTH |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02190-2333 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 781-348-3900 |
Mailing Address - Fax: | 781-348-2132 |
Practice Address - Street 1: | 250 POND ST |
Practice Address - Street 2: | |
Practice Address - City: | BRAINTREE |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02184-5351 |
Practice Address - Country: | US |
Practice Address - Phone: | 781-348-3900 |
Practice Address - Fax: | 781-348-2132 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-17 |
Last Update Date: | 2011-09-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 6107 | 103G00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 0525928 | Medicaid | |
MA | 751147 | Other | TUFTS HEALTH PLAN |
MA | W04900 | Other | BLUE CROSS BLUE SHIELD |
MA | 043558206 | Other | TAX ID |
MA | W04900 | Medicare ID - Type Unspecified |