1417069410 NPI number — BROOKSIDE COUNSELING ASSOCIATES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417069410 NPI number — BROOKSIDE COUNSELING ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSIDE COUNSELING ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417069410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 DERBY ST
Provider Second Line Business Mailing Address:
STE 13
Provider Business Mailing Address City Name:
HINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-749-4600
Provider Business Mailing Address Fax Number:
781-741-8341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 DERBY ST
Provider Second Line Business Practice Location Address:
STE 13
Provider Business Practice Location Address City Name:
HINGHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-749-4600
Provider Business Practice Location Address Fax Number:
781-741-8341
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ECKELMAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
781-749-4600

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 667145 . This is a "TUFTS HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1005990 . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P10213 . This is a "BCBS FOR CLINICAL SOCIAL" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W10414 . This is a "BCBS FOR PSYCHOLOGISTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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