Provider Demographics
NPI:1366593386
Name:CUETARA, JOHN MONROE (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MONROE
Last Name:CUETARA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:41 PITCHER AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2106
Mailing Address - Country:US
Mailing Address - Phone:781-488-3294
Mailing Address - Fax:781-488-3254
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 407
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-488-3294
Practice Address - Fax:781-488-3254
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7201103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1895613Medicaid