Provider Demographics
NPI:1164630612
Name:HEILBRUNN, LORRAINE JUDITH (PHD)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:JUDITH
Last Name:HEILBRUNN
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 1:1752 BEACON ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-2157
Mailing Address - Country:US
Mailing Address - Phone:617-566-7538
Mailing Address - Fax:
Practice Address - Street 1:1752 BEACON ST
Practice Address - Street 2:UNIT 3
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-2157
Practice Address - Country:US
Practice Address - Phone:617-566-7538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHEWO50756Medicare ID - Type Unspecified