Healthcare Provider Details

I. General information

NPI: 1669721429
Provider Name (Legal Business Name): JULIE THAYER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 WORCESTER ST
WELLESLEY MA
02481-5420
US

IV. Provider business mailing address

83 HOLLY LN
HOLLISTON MA
01746-2521
US

V. Phone/Fax

Practice location:
  • Phone: 781-431-5270
  • Fax:
Mailing address:
  • Phone: 774-232-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS01758
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10326
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: