Provider Demographics
NPI:1235287400
Name:FANTINI, PAMELA (PHD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:FANTINI
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 1:7 MILL POND
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2686
Mailing Address - Country:US
Mailing Address - Phone:781-639-2359
Mailing Address - Fax:978-745-5455
Practice Address - Street 1:20 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3739
Practice Address - Country:US
Practice Address - Phone:781-639-2359
Practice Address - Fax:978-745-5455
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY4599103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA713383OtherTUFTS HEALTH PLAN
MA062918000OtherMAGELLAN
W04460OtherBCBSMA
MA124611OtherVALUEOPTIOMS
W04460OtherBCBSMA