Provider Demographics
NPI:1912070798
Name:UNTCH, ANDREW (EDD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:UNTCH
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 MOUNT AUBURN ST
Mailing Address - Street 2:CLARK 1
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5502
Mailing Address - Country:US
Mailing Address - Phone:617-499-5054
Mailing Address - Fax:617-499-5465
Practice Address - Street 1:330 MOUNT AUBURN ST
Practice Address - Street 2:CLARK 1
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-499-5054
Practice Address - Fax:617-499-5465
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06479OtherBLUE CROSS
MAW06479OtherBLUE CROSS