Provider Demographics
NPI:1598971459
Name:BIBULD, LISA F (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:F
Last Name:BIBULD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 ALBANY STREET
Mailing Address - Street 2:FLOOR GROUND
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11300103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110165671AMedicaid