Provider Demographics
NPI:1881614436
Name:MORTARELLI, PAUL L (PHD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:MORTARELLI
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 1:24 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1215
Mailing Address - Country:US
Mailing Address - Phone:508-460-3190
Mailing Address - Fax:508-460-3297
Practice Address - Street 1:24 NEWTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1215
Practice Address - Country:US
Practice Address - Phone:508-460-3190
Practice Address - Fax:508-460-3297
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6308103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50483Medicare ID - Type Unspecified