Provider Demographics
NPI:1013153345
Name:MENGWASSER, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MENGWASSER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BIRCHWOOD AVE.
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106
Mailing Address - Country:US
Mailing Address - Phone:413-754-3330
Mailing Address - Fax:
Practice Address - Street 1:367 PINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1930
Practice Address - Country:US
Practice Address - Phone:413-737-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health