Basic Information
| Provider Information | |||||||||
| NPI: | 1548648918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUFFY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LEO | ||||||||
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| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 HIGH ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024530577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084045733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 BURLINGTON RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818623600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1004745 | 01 | MA | NHP | OTHER | 0000023532 | 01 | MA | BMC | OTHER | 042611055 | 01 | MA | TAX ID | OTHER | 1004745 | 01 | MA | FALLON | OTHER | 99618201 | 01 | MA | NETWORK HEALTH | OTHER | M18633 | 01 | MA | BCBS | OTHER | 13003287 | 01 | MA | MBHP | OTHER |