Provider Demographics
NPI:1255878575
Name:SONG, RACHEL (PHD)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 CANAL ST UNIT 807
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-4341
Mailing Address - Country:US
Mailing Address - Phone:516-477-8319
Mailing Address - Fax:
Practice Address - Street 1:687 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494
Practice Address - Country:US
Practice Address - Phone:781-559-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021618103G00000X, 103TC0700X
HIPSY-1637103G00000X
MA10877103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical