Provider Demographics
NPI:1285674184
Name:MERMELSTEIN, BRUCE L (EDD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
Last Name:MERMELSTEIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WALNUT PL
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1716
Mailing Address - Country:US
Mailing Address - Phone:617-969-8694
Mailing Address - Fax:
Practice Address - Street 1:21 WALNUT PL
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1716
Practice Address - Country:US
Practice Address - Phone:617-527-4610
Practice Address - Fax:617-527-6829
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3460103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO3550Medicare UPIN