Healthcare Provider Details

I. General information

NPI: 1578641171
Provider Name (Legal Business Name): DEBORAH BETH KULICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

IV. Provider business mailing address

236 CROSS ST
BELMONT MA
02478-4238
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-2629
  • Fax:
Mailing address:
  • Phone: 617-935-1159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number231096
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number231096
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: