Provider Demographics
NPI:1194804062
Name:DETORA, DANIELLE (PSYD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DETORA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1666 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5317
Mailing Address - Country:US
Mailing Address - Phone:781-862-6772
Mailing Address - Fax:
Practice Address - Street 1:1666 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5317
Practice Address - Country:US
Practice Address - Phone:781-862-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8063103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADE W51215Medicare ID - Type UnspecifiedPART B