Basic Information
| Provider Information | |||||||||
| NPI: | 1346720646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL COMMUNITY PSYCHOTHERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 264 UNION AVE APT 2 | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017026348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742444128 | ||||||||
| FaxNumber: | 7742444129 | ||||||||
| Practice Location | |||||||||
| Address1: | 264 UNION AVE APT 2 | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017026348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087335951 | ||||||||
| FaxNumber: | 5083211960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | AKINKUOYE | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | OLUSOLA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5087335951 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PMHNP-BC, DNP | ||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 233605 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163WP0809X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1366796088 | 01 | MA | COMMONWEALTH CARE ALLIANCE | OTHER | 110110469A | 05 | MA | MEDICAID | 1366796088 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |