Provider Demographics
NPI:1932390838
Name:THURSTON, IDIA BINITIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:IDIA
Middle Name:BINITIE
Last Name:THURSTON
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 1:19 HALIFAX ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4306
Mailing Address - Country:US
Mailing Address - Phone:813-789-1361
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:857-218-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9520103TC2200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent