Healthcare Provider Details

I. General information

NPI: 1063070191
Provider Name (Legal Business Name): JOANNA M STRECK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 10/20/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BLOSSOM STREET COX 110
BOSTON MA
02114-2606
US

IV. Provider business mailing address

100 CAMBRIDGE ST FL 16
BOSTON MA
02114-2509
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-9977
  • Fax:
Mailing address:
  • Phone: 617-643-9977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11522
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number11522
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number11522
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11522
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number11522
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: