Provider Demographics
NPI:1134104623
Name:ROSENBERG, LAWRENCE GENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:GENE
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LEONARD AVE
Mailing Address - Street 2:#2
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1020
Mailing Address - Country:US
Mailing Address - Phone:617-491-1085
Mailing Address - Fax:617-876-3494
Practice Address - Street 1:1105 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 3F
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5221
Practice Address - Country:US
Practice Address - Phone:617-491-1085
Practice Address - Fax:617-876-3494
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5018103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04716OtherBC/BS OF MASSACHUSETTS
MAW04716OtherBC/BS OF MASSACHUSETTS