Provider Demographics
NPI:1073282596
Name:BAYSTATE PEDIATRIC NEUROPSYCHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:BAYSTATE PEDIATRIC NEUROPSYCHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KILEY-BRABECK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:978-276-4041
Mailing Address - Street 1:352 PARK ST STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH READING
Mailing Address - State:MA
Mailing Address - Zip Code:01864-2158
Mailing Address - Country:US
Mailing Address - Phone:978-276-4041
Mailing Address - Fax:978-207-1007
Practice Address - Street 1:352 PARK ST STE 208
Practice Address - Street 2:
Practice Address - City:NORTH READING
Practice Address - State:MA
Practice Address - Zip Code:01864-2158
Practice Address - Country:US
Practice Address - Phone:978-276-4041
Practice Address - Fax:978-207-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1124214309OtherPERSONAL NPI