MEDICARE: JULIE GARDNER MANDEL PHD

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	103T00000X	Psychologist	6776	MA
2	103TC0700X	Clinical Psychologist	6776	MA

General Provider Information

NPI Number	:	1720062730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE GARDNER MANDEL PHD

Provider Business Mailing Address
First Line	:	100 WOODCLIFF RD
Second Line	:
City	:	NEWTON HIGHLANDS
State	:	MA
Zip	:	02461-1845
Country	:	US
Telephone Number	:	617-733-5438
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WOODCLIFF RD
Second Line	:
City	:	NEWTON HIGHLANDS
State	:	MA
Zip	:	02461-1845
Country	:	US
Telephone Number	:	617-733-5438
Fax Number	:

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	01/06/2024

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