Provider Demographics
NPI:1043797582
Name:LU, EDA Y (MS, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:EDA
Middle Name:Y
Last Name:LU
Suffix:
Gender:F
Credentials:MS, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MISSION PARK DR APT 305
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6210
Mailing Address - Country:US
Mailing Address - Phone:617-682-6501
Mailing Address - Fax:
Practice Address - Street 1:85 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458
Practice Address - Country:US
Practice Address - Phone:617-923-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
MA3567-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker