Provider Demographics
NPI:1932172632
Name:LIFEDIMENSIONS NEUROPSYCHOLOGICAL SERVICES, INC
Entity Type:Organization
Organization Name:LIFEDIMENSIONS NEUROPSYCHOLOGICAL SERVICES, INC
Other - Org Name:LIFESPAN SERVICES, INC. OR LIFESPAN NEUROPSYCHOLOGICAL SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLERK, CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-348-3900
Mailing Address - Street 1:250 POND ST
Mailing Address - Street 2:LIFEDIMENSIONS NEUROPSYCHOLOGICAL SERVICES, INC.
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5351
Mailing Address - Country:US
Mailing Address - Phone:781-348-2258
Mailing Address - Fax:781-348-2132
Practice Address - Street 1:250 POND ST
Practice Address - Street 2:LIFEDIMENSIONS NEUROPSYCHOLOGICAL SERVICES, INC.
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5351
Practice Address - Country:US
Practice Address - Phone:781-348-2258
Practice Address - Fax:781-348-2132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEDIMENSIONS NEUROPSYCHOLOGICAL SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-12
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4712103G00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9721771Medicaid
MAW10469OtherBCBS
MAW10469OtherBCBS