Provider Demographics
NPI:1780771758
Name:WATTENBERG, MELISSA SUZANNEMARIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:SUZANNEMARIA
Last Name:WATTENBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:SUZANNEMARIA
Other - Last Name:WATTENBERG-ULARICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:251 CAUSEWAY ST
Mailing Address - Street 2:VA BOSTON HEALTHCARE SYSTEM OUTPATIENT CLINIC
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2148
Mailing Address - Country:US
Mailing Address - Phone:617-248-1089
Mailing Address - Fax:617-248-1287
Practice Address - Street 1:251 CAUSEWAY ST
Practice Address - Street 2:VA BOSTON HEALTHCARE SYSTEM OUTPATIENT CLINIC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2148
Practice Address - Country:US
Practice Address - Phone:617-248-1089
Practice Address - Fax:617-248-1287
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6346103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA006346OtherTUFTS PROVIDER NUMBER
MAW05873OtherBCBS PROVIDER #
MA6346OtherMA LICENSE #
MA1892894Medicaid
MA1892894Medicaid