Provider Demographics
NPI:1821025800
Name:ROSENBAUM, JOEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:
Last Name:ROSENBAUM
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 1:36 HALVORSEN AVE
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 WHITWELL ST
Practice Address - Street 2:QUINCY MEDICAL CENTER, SUITE B618
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1870
Practice Address - Country:US
Practice Address - Phone:617-376-2095
Practice Address - Fax:617-376-5413
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA05087103G00000X, 103TB0200X, 103TC0700X, 103T00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0526894Medicaid
MA403324OtherTUFTS PROVIDER ID
MAW05943OtherBLUE CROSS/BLUE SHIELD ID
MAW50336Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID