Provider Demographics
NPI:1730370032
Name:ENGGASSER, JUSTIN LEO (PHD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEO
Last Name:ENGGASSER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S. HUNTINGTON AVENUE
Mailing Address - Street 2:VA BOSTON HEALTHCARE SYSTEM (116B)
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:774-826-1380
Mailing Address - Fax:
Practice Address - Street 1:150 S. HUNTINGTON AVENUE
Practice Address - Street 2:VA BOSTON HEALTHCARE SYSTEM (116B)
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:774-826-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8807103TA0400X, 103TC0700X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral