Provider Demographics
NPI:1053559377
Name:PACKARD, JULIE GORDON
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:GORDON
Last Name:PACKARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HARVEST HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5788
Mailing Address - Country:US
Mailing Address - Phone:207-595-7233
Mailing Address - Fax:
Practice Address - Street 1:111 HARVEST HILL RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5788
Practice Address - Country:US
Practice Address - Phone:207-595-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431896800Medicaid