Provider Demographics
NPI:1225651375
Name:WEIZENBAUM, EMMA LORRAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:EMMA
Middle Name:LORRAINE
Last Name:WEIZENBAUM
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 1:117 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2705
Mailing Address - Country:US
Mailing Address - Phone:512-217-2825
Mailing Address - Fax:
Practice Address - Street 1:60 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6128
Practice Address - Country:US
Practice Address - Phone:617-525-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-23
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11981103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty