Provider Demographics
NPI:1417902099
Name:DOMAR, ALICE DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:DIANE
Last Name:DOMAR
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 1:130 2ND AVE
Mailing Address - Street 2:BOSTON IVF - DOMAR CENTER
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1100
Mailing Address - Country:US
Mailing Address - Phone:781-434-6578
Mailing Address - Fax:781-370-2330
Practice Address - Street 1:130 2ND AVE
Practice Address - Street 2:BOSTON IVF - DOMAR CENTER
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1100
Practice Address - Country:US
Practice Address - Phone:781-434-6578
Practice Address - Fax:781-370-2330
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4308103TB0200X, 103TC0700X, 103TC1900X, 103TF0000X, 103TH0100X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04271Medicare ID - Type Unspecified
MAE23404Medicare UPIN