Provider Demographics
NPI:1306912415
Name:MACK, JULIE M (PHD PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:24 ROCKLAND ST
Mailing Address - Street 2:UNIT 7 HANOVER PSYCHOLOGICAL ASSOCIATES
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-2226
Mailing Address - Country:US
Mailing Address - Phone:781-826-8228
Mailing Address - Fax:781-826-0965
Practice Address - Street 1:24 ROCKLAND ST
Practice Address - Street 2:UNIT 7 HANOVER PSYCHOLOGICAL ASSOCIATES
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2226
Practice Address - Country:US
Practice Address - Phone:781-826-8228
Practice Address - Fax:781-826-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA3769103G00000X, 103TF0200X
MA3679103TC0700X
MAB769103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0515299Medicaid
6151458OtherUNITED
4545006OtherAETNA
000821OtherVALUE OPTIONS
3249700821OtherHARVARD PILGRIM
703727Other1ST HEALTH
009484OtherTRICARE
1007070OtherBEACON HEALTH
202886OtherMHN
M62937Other1ST SENIORITY
111631000OtherMAGELLAN
767861OtherTUFTS
703727Other1ST HEALTH
W03737Medicare UPIN