Provider Demographics
NPI:1568594463
Name:JULIA, GWEN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:W
Last Name:JULIA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:WOODIWISS
Other - Last Name:JULIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:60 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2307
Mailing Address - Country:US
Mailing Address - Phone:617-965-2956
Mailing Address - Fax:617-244-8363
Practice Address - Street 1:60 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2307
Practice Address - Country:US
Practice Address - Phone:617-965-2956
Practice Address - Fax:617-244-8363
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14174OtherNATL REG OF HLTH PROV PSY
MAWO 1179Medicare ID - Type UnspecifiedBLUE CROSS BLUE SHIELD