Provider Demographics
NPI:1063586451
Name:NACE, ROBERT FREDERICK (PSYD, MDIV)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:FREDERICK
Last Name:NACE
Suffix:
Gender:M
Credentials:PSYD, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WINSLOW ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-1730
Mailing Address - Country:US
Mailing Address - Phone:617-361-4563
Mailing Address - Fax:
Practice Address - Street 1:17 WINSLOW ST
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-1730
Practice Address - Country:US
Practice Address - Phone:617-240-6713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8042103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1857258OtherMASSHEALTH
MAW06259OtherBLUECROSSBLUESHIELD
MAW51129Medicare ID - Type Unspecified