Provider Demographics
NPI:1588321392
Name:TVELIAJR, BRIAN M
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:TVELIAJR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:M
Other - Last Name:TVELIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:55 LAKE AVENUE NORTH
Mailing Address - Street 2:DEPARTMENT OF PSYCHIATRY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655
Mailing Address - Country:US
Mailing Address - Phone:774-303-2986
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVENUE NORTH
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:774-303-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0338RC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist