Healthcare Provider Details

I. General information

NPI: 1013141993
Provider Name (Legal Business Name): NORA ILNICZKY, PH.D., PSYCHOTHERAPY AND WELLBEING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 MASSACHUSETTS AVE SUITE #307
CAMBRIDGE MA
02138-5205
US

IV. Provider business mailing address

1158 MASSACHUSETTS AVE SUITE #307
CAMBRIDGE MA
02138-5205
US

V. Phone/Fax

Practice location:
  • Phone: 617-894-0055
  • Fax:
Mailing address:
  • Phone: 617-894-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number8701
License Number StateMA

VIII. Authorized Official

Name: DR. NORA KLARA ILNICZKY
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 617-894-0055