Provider Demographics
NPI:1003011388
Name:ICCD PARTNERS
Entity Type:Organization
Organization Name:ICCD PARTNERS
Other - Org Name:INTEGRATED CENTER FOR CHILD DEVELOPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLDOVER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-641-0900
Mailing Address - Street 1:340 TURNPIKE ST
Mailing Address - Street 2:SUITE 11A
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2700
Mailing Address - Country:US
Mailing Address - Phone:617-641-0900
Mailing Address - Fax:617-641-0930
Practice Address - Street 1:340 TURNPIKE ST
Practice Address - Street 2:SUITE 11A
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2700
Practice Address - Country:US
Practice Address - Phone:617-641-0900
Practice Address - Fax:617-641-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty