Provider Demographics
NPI:1720062730
Name:MANDEL, JULIE GARDNER (PHD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:GARDNER
Last Name:MANDEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:100 WOODCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON HIGHLANDS
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1845
Mailing Address - Country:US
Mailing Address - Phone:617-733-5438
Mailing Address - Fax:
Practice Address - Street 1:100 WOODCLIFF RD
Practice Address - Street 2:
Practice Address - City:NEWTON HIGHLANDS
Practice Address - State:MA
Practice Address - Zip Code:02461-1845
Practice Address - Country:US
Practice Address - Phone:617-733-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6776103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05366Medicare ID - Type Unspecified