Provider Demographics
NPI:1932147261
Name:GERSON, PAULINE ETTA (PSYD)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ETTA
Last Name:GERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:468 GREAT RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4102
Mailing Address - Country:US
Mailing Address - Phone:978-635-0509
Mailing Address - Fax:978-635-9301
Practice Address - Street 1:468 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4102
Practice Address - Country:US
Practice Address - Phone:978-635-0509
Practice Address - Fax:978-635-9301
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6517103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGE-W05212Medicare ID - Type UnspecifiedMEDICARE