Provider Demographics
NPI:1720713019
Name:JULIEN, KINGDOLPH M
Entity Type:Individual
Prefix:
First Name:KINGDOLPH
Middle Name:M
Last Name:JULIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1861 MIDDLESEX ST APT 300
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-1134
Mailing Address - Country:US
Mailing Address - Phone:857-452-2190
Mailing Address - Fax:
Practice Address - Street 1:1861 MIDDLESEX ST APT 300
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-1134
Practice Address - Country:US
Practice Address - Phone:857-452-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS16842317106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician