Provider Demographics
NPI:1083693246
Name:MONDELL, SID H (PHD)
Entity Type:Individual
Prefix:DR
First Name:SID
Middle Name:H
Last Name:MONDELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 WASHINGTON ST
Mailing Address - Street 2:SUITE 434
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-4634
Mailing Address - Country:US
Mailing Address - Phone:617-338-9533
Mailing Address - Fax:617-726-3514
Practice Address - Street 1:294 WASHINGTON ST
Practice Address - Street 2:SUITE 434
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4634
Practice Address - Country:US
Practice Address - Phone:617-338-9533
Practice Address - Fax:617-726-3514
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02838-68Medicare ID - Type Unspecified