1518164508 NPI number — THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN

Table of content: (NPI 1518164508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518164508 NPI number — THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN
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:
6
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:
1518164508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 CABOT ROAD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-393-5150
Provider Business Mailing Address Fax Number:
781-393-5169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 CABOT ROAD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-393-5150
Provider Business Practice Location Address Fax Number:
781-393-5169
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FITZGERALD
Authorized Official First Name:
ANN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
781-393-5150

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 404J , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1518164508 . This is a "MBHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "FALLON COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 963959-01 . This is a "NETWORK" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 288472 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1031830 . This is a "BEACON HEALTH STRATEGIES (NHP)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "BEACON (BMC)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110081507B , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0015666 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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