Provider Demographics
NPI:1134267115
Name:PURVIS, DAVID FITZGERALD (LADC-1)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:FITZGERALD
Last Name:PURVIS
Suffix:
Gender:M
Credentials:LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MARSHALLS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4442
Mailing Address - Country:US
Mailing Address - Phone:508-578-3108
Mailing Address - Fax:
Practice Address - Street 1:55 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1029
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1158101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)