Provider Demographics
NPI:1174604979
Name:BIRNBAUM, MORTON PAUL (PHD)
Entity type:Individual
Prefix:DR
First Name:MORTON
Middle Name:PAUL
Last Name:BIRNBAUM
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 1:22 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-2408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 BOSTON POST RD
Practice Address - Street 2:SUITE 34
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-3014
Practice Address - Country:US
Practice Address - Phone:978-443-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA402103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01579OtherBLUE CROSS/BLUE SHIELD