Provider Demographics
NPI:1336217629
Name:WIZNITZER, EILEEN R (PSYD)
Entity type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:R
Last Name:WIZNITZER
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 1:38 WACHUSETT DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6913
Mailing Address - Country:US
Mailing Address - Phone:339-223-6002
Mailing Address - Fax:
Practice Address - Street 1:5 WATSON RD
Practice Address - Street 2:#101
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3924
Practice Address - Country:US
Practice Address - Phone:339-223-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4514103T00000X, 103TC0700X
103TC2200X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0519979Medicaid
MA0519979Medicaid