Provider Demographics
NPI:1912197211
Name:LIVERANT, GABRIELLE ITTA (PHD)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ITTA
Last Name:LIVERANT
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 1:185 DEVONSHIRE ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1407
Mailing Address - Country:US
Mailing Address - Phone:617-721-8445
Mailing Address - Fax:
Practice Address - Street 1:185 DEVONSHIRE ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1407
Practice Address - Country:US
Practice Address - Phone:617-721-8445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10165103TC0700X
RIPS01138103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical