1548356363 NPI number — DR. THERESA ELAINE GILMORE PH.D.

Table of content: DR. THERESA ELAINE GILMORE PH.D. (NPI 1548356363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548356363 NPI number — DR. THERESA ELAINE GILMORE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
THERESA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548356363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1683 BEACON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLINE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02445-4495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-461-6936
Provider Business Mailing Address Fax Number:
617-353-5539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1683 BEACON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02445-4495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-461-6936
Provider Business Practice Location Address Fax Number:
617-353-5539
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  989 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY-2023-0082 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 7990 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2053338 . This is a "CIGNA PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W06227 . This is a "BLUE CROSS BLUE SHIELD #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7813643 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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