MEDICARE: JULEE MARIE DOUGLASS LADCII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	22842	MA

General Provider Information

NPI Number	:	1174362867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULEE MARIE DOUGLASS LADCII

Provider Business Mailing Address
First Line	:	564 MAIN ST STE 100
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02452-5559
Country	:	US
Telephone Number	:	781-317-0005
Fax Number	:

Provider Business Practice Location Address
First Line	:	564 MAIN ST STE 100
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02452-5559
Country	:	US
Telephone Number	:	781-317-0005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	05/22/2024

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