Provider Demographics
NPI:1316290869
Name:LIZARRALDE, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:LIZARRALDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 BERKELEY ST FL 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6230
Mailing Address - Country:US
Mailing Address - Phone:617-350-6900
Mailing Address - Fax:
Practice Address - Street 1:95 BERKELEY ST FL 6
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-6230
Practice Address - Country:US
Practice Address - Phone:617-350-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor