Provider Demographics
NPI:1386710929
Name:PINGALORE, MARYANN A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:A
Last Name:PINGALORE
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 1:21 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760
Mailing Address - Country:US
Mailing Address - Phone:508-653-1489
Mailing Address - Fax:508-651-0830
Practice Address - Street 1:196 BOSTON AVE
Practice Address - Street 2:SUITE 2500
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-396-3856
Practice Address - Fax:508-651-0830
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3269103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPIW03364OtherBLUE CROSS BLUE SHIELD OF
MAPIW03364OtherBLUE CROSS BLUE SHIELD OF