Provider Demographics
NPI:1033428495
Name:PEPPER, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:PEPPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BEACONSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-3302
Mailing Address - Country:US
Mailing Address - Phone:904-415-6946
Mailing Address - Fax:
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-6700
Practice Address - Country:US
Practice Address - Phone:781-885-0466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME840972084P0800X
MA497792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6190782Medicaid
MA6190782Medicaid
MAJ02804Medicare PIN