Provider Demographics
NPI:1457843054
Name:BUCCI LIDDY, COLLEEN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:M
Last Name:BUCCI LIDDY
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 1:867 BOYLSTON ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2774
Mailing Address - Country:US
Mailing Address - Phone:617-918-7394
Mailing Address - Fax:
Practice Address - Street 1:867 BOYLSTON ST FL 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2774
Practice Address - Country:US
Practice Address - Phone:617-918-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11442103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical