Provider Demographics
NPI:1558432781
Name:LIFTIK, JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:LIFTIK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 POND AVE
Mailing Address - Street 2:806
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7141
Mailing Address - Country:US
Mailing Address - Phone:617-254-4136
Mailing Address - Fax:
Practice Address - Street 1:1853 COMMONWEALTH AVE
Practice Address - Street 2:7
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-5498
Practice Address - Country:US
Practice Address - Phone:617-254-4136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01457Medicare ID - Type Unspecified