Provider Demographics
NPI:1962176453
Name:SANTORELLI, GENNARINA DIANE (PHD)
Entity type:Individual
Prefix:
First Name:GENNARINA
Middle Name:DIANE
Last Name:SANTORELLI
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 1:185 PILGRIM ROAD
Mailing Address - Street 2:DEACONESS 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:718-490-8133
Mailing Address - Fax:
Practice Address - Street 1:185 PILGRIM ROAD
Practice Address - Street 2:DEACONESS 1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-632-0908
Practice Address - Fax:617-754-8638
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical