Provider Demographics
NPI:1255611042
Name:IGUCHI, LISA (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:IGUCHI
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 1:339 WASHINGTON ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:339 WASHINGTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1870
Practice Address - Country:US
Practice Address - Phone:781-738-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01243103G00000X
MA9365103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist