Basic Information
| Provider Information | |||||||||
| NPI: | 1023224383 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MWA, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | RIVERBEND MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135987777 | ||||||||
| FaxNumber: | 4135987722 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CHICOPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010201969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135987777 | ||||||||
| FaxNumber: | 4135987722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOUNSBURY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4137896800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.