Provider Demographics
NPI:1275679771
Name:TAL, ILANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILANA
Middle Name:
Last Name:TAL
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 1:872 MASS AVE
Mailing Address - Street 2:SUITE 2-5
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1836
Mailing Address - Country:US
Mailing Address - Phone:617-864-0285
Mailing Address - Fax:
Practice Address - Street 1:872 MASS AVE
Practice Address - Street 2:SUITE 2-5
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1836
Practice Address - Country:US
Practice Address - Phone:617-864-0285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06492OtherBCBS