Provider Demographics
NPI:1487652483
Name:DECKEL, ALBERT WALLACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:WALLACE
Last Name:DECKEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:W
Other - Last Name:DECKEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:NORTH GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01536-0605
Mailing Address - Country:US
Mailing Address - Phone:508-393-3820
Mailing Address - Fax:508-393-3814
Practice Address - Street 1:382 W MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-2157
Practice Address - Country:US
Practice Address - Phone:508-393-3820
Practice Address - Fax:505-393-3814
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8183103G00000X, 103T00000X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0522791Medicaid
MAR08598Medicare UPIN
MA0522791Medicaid