Provider Demographics
NPI:1649536020
Name:LICHT, ILANA (PHD)
Entity type:Individual
Prefix:DR
First Name:ILANA
Middle Name:
Last Name:LICHT
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 1:3 BOW ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5109
Mailing Address - Country:US
Mailing Address - Phone:161-754-7225
Mailing Address - Fax:617-547-0003
Practice Address - Street 1:3 BOW ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5109
Practice Address - Country:US
Practice Address - Phone:161-754-7225
Practice Address - Fax:617-547-0003
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical