Basic Information
| Provider Information | |||||||||
| NPI: | 1558713156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACDONALD | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RODERICK | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 340 THOMPSON RD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015701509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089432600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2016 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN2310388 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.