Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 4389 | MA |
N | 103T00000X | Psychologist | 4389 | MA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 4389 | MA |
N | 103TA0700X | Adult Development & Aging Psychologist | 4389 | MA |
N | 103G00000X | Clinical Psychologist | 4389 | MA |
N | 103TC0700X | Clinical Psychologist | 4389 | MA |
NPI | 1134280365 |
---|---|
Provider Name | Dr. Laurence Weisman |
First Address | Wellesley, MA 02482-7900 |
Second Address | Wellesley, MA 02482-7900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
W04265 | BC-BS PROVIDER (01) | MA |