Doctor Name: | MATTHEW SCOTT WILLERICK |
NPI Number: | 1497082390 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PH.D. |
License Number: | 6301014957 |
Business Practice Address: | 90 Vandenberg Dr 66 Mds/mental Health Clinic Hanscom Afb, MA - 017312104 |
Business Phone Number: | 7812256392 |
Business Fax Number: | |
Mailing Address: | 34 Upland Rd, WALTHAM |
State: | MA |
Postal Code: | 024512988 |
Phone Number: | 2693778099 |
Fax Number: | |
NPI Enumeration Date: | 11/13/2009 |
NPI Last Update Date: | 11/04/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 6301014957 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |