Provider Demographics
NPI:1881625309
Name:SCANLON, PETER J (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:SCANLON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BELMONT ST
Mailing Address - Street 2:SOUTH BAY
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5299
Mailing Address - Country:US
Mailing Address - Phone:508-559-0473
Mailing Address - Fax:508-584-2227
Practice Address - Street 1:37 BELMONT ST
Practice Address - Street 2:SOUTH BAY
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5299
Practice Address - Country:US
Practice Address - Phone:508-559-0473
Practice Address - Fax:508-584-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2620103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02732Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER