Provider Demographics
NPI:1104816164
Name:TAVILLA, CYNTHIA S (PSYD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:S
Last Name:TAVILLA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:S
Other - Last Name:KEEFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:9 MERIAM ST
Mailing Address - Street 2:. SUITE 25
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5300
Mailing Address - Country:US
Mailing Address - Phone:781-863-5570
Mailing Address - Fax:
Practice Address - Street 1:9 MERIAM ST
Practice Address - Street 2:. SUITE 25
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5300
Practice Address - Country:US
Practice Address - Phone:781-863-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7549103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKEW50972Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST