Healthcare Provider Details

I. General information

NPI: 1962467787
Provider Name (Legal Business Name): JUDITH M TULLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 E MAIN ST
WESTBORO MA
01581
US

IV. Provider business mailing address

1330 BEACON ST STE 205
BROOKLINE MA
02446
US

V. Phone/Fax

Practice location:
  • Phone: 508-870-0647
  • Fax: 508-799-6325
Mailing address:
  • Phone: 617-730-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106057
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: