Provider Demographics
NPI:1285646695
Name:WIEGARTZ, PAMELA (PHD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WIEGARTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 E CENTRAL ST STE 247
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-1317
Mailing Address - Country:US
Mailing Address - Phone:617-429-8584
Mailing Address - Fax:
Practice Address - Street 1:279 E CENTRAL ST STE 247
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-1317
Practice Address - Country:US
Practice Address - Phone:617-429-8584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0710061142084P0800X
MA8952103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
594560Medicare PIN