Provider Demographics
NPI:1346241932
Name:IMBER, MICHELLE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:IMBER
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:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-1927
Mailing Address - Country:US
Mailing Address - Phone:617-487-8910
Mailing Address - Fax:866-338-3269
Practice Address - Street 1:125 NASHUA ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-1101
Practice Address - Country:US
Practice Address - Phone:617-487-8910
Practice Address - Fax:866-338-3269
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8203103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist