Provider Demographics
NPI:1255351037
Name:TETENBAUM, DONALD (PSYD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:TETENBAUM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HARLOW DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1410
Mailing Address - Country:US
Mailing Address - Phone:413-549-5727
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEWOOD PL
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1075
Practice Address - Country:US
Practice Address - Phone:800-535-5526
Practice Address - Fax:781-871-5973
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6029103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W05195Medicare ID - Type Unspecified