Provider Demographics
NPI:1023284460
Name:MARY PANTUHOVA, PSY.D., LLC
Entity type:Organization
Organization Name:MARY PANTUHOVA, PSY.D., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KNORRING
Authorized Official - Last Name:PANTUHOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-332-7596
Mailing Address - Street 1:91 WYMAN ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1529
Mailing Address - Country:US
Mailing Address - Phone:617-332-7596
Mailing Address - Fax:
Practice Address - Street 1:91 WYMAN ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-1529
Practice Address - Country:US
Practice Address - Phone:617-332-7596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6733103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW40013Medicare UPIN