Provider First Line Business Practice Location Address:
170 GOVERNORS AVENUE
Provider Second Line Business Practice Location Address:
LAWRENCE MEMORIAL HOSPITAL PSYCH
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:
781-306-6150
Provider Business Practice Location Address Fax Number:
781-306-6147
Provider Enumeration Date:
11/21/2005