Provider Demographics
NPI:1992874978
Name:MOGILNICKI, THADDEUS RONALD (EDD)
Entity type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:RONALD
Last Name:MOGILNICKI
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SHAWME RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02563-2336
Mailing Address - Country:US
Mailing Address - Phone:508-888-4721
Mailing Address - Fax:508-747-5209
Practice Address - Street 1:323 COURT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4322
Practice Address - Country:US
Practice Address - Phone:508-747-2718
Practice Address - Fax:508-747-5209
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA912103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA468604OtherTUFTS
MA1895532Medicaid
MAW01662OtherBC BS INDEMNITY
MA2168630OtherCIGNA GROUP
MA213380OtherNEIGHBORHOOD HEALTH GROUP
MA311299OtherMHN
MA000000030825OtherBOSTON MEDICAL HEALTH NET
MA497004OtherVAUE OPTIONS
MAM19000OtherBC BS HMO GROUP
MA1895532Medicaid
MAW01662OtherBC BS INDEMNITY