Healthcare Provider Details

I. General information

NPI: 1205218468
Provider Name (Legal Business Name): EMILY IPPOLITO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 MAIN ST
LUNENBURG MA
01462-1428
US

IV. Provider business mailing address

103D RIDGEFIELD CIR
CLINTON MA
01510-1431
US

V. Phone/Fax

Practice location:
  • Phone: 978-956-3266
  • Fax:
Mailing address:
  • Phone: 586-291-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-59494
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: