Provider Demographics
NPI:1033685862
Name:GINBERG-NIELSEN, ILYSE L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ILYSE
Middle Name:L
Last Name:GINBERG-NIELSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 GREAT PLAIN AVE # 197
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3031
Mailing Address - Country:US
Mailing Address - Phone:847-738-0022
Mailing Address - Fax:781-235-1877
Practice Address - Street 1:12 CEDAR TER
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-5437
Practice Address - Country:US
Practice Address - Phone:847-738-0022
Practice Address - Fax:781-235-1877
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9120103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical