Provider Demographics
NPI:1891368510
Name:LIDRBAUCH, IZABELLA (MA, LMHC)
Entity type:Individual
Prefix:
First Name:IZABELLA
Middle Name:
Last Name:LIDRBAUCH
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 OAK ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1493
Mailing Address - Country:US
Mailing Address - Phone:617-977-5372
Mailing Address - Fax:
Practice Address - Street 1:109 OAK ST STE 201
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1493
Practice Address - Country:US
Practice Address - Phone:617-977-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 225A00000X
MALMHC10003206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist