Healthcare Provider Details

I. General information

NPI: 1053747659
Provider Name (Legal Business Name): INTEGRATED ASSESSMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1753 MASSACHUSETTS AVE
CAMBRIDGE MA
02140-2231
US

IV. Provider business mailing address

1753 MASSACHUSETTS AVE
CAMBRIDGE MA
02140-2231
US

V. Phone/Fax

Practice location:
  • Phone: 617-661-1100
  • Fax: 617-661-1101
Mailing address:
  • Phone: 617-661-1100
  • Fax: 617-661-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7822
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7822
License Number StateMA

VIII. Authorized Official

Name: DR. MELINDA EILEEN KULISH
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 617-661-1100