Basic Information
| Provider Information | |||||||||
| NPI: | 1639201544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARVISTA PSYCHOLOGICAL ASSOCIATE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 PARKINGWAY | ||||||||
| Address2: | P.O.BOX 146 | ||||||||
| City: | COHASSET | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813830860 | ||||||||
| FaxNumber: | 7813831239 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 PARKINGWAY | ||||||||
| Address2: | |||||||||
| City: | COHASSET | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813830860 | ||||||||
| FaxNumber: | 7813831239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MUNDHENK | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7813830860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.