Provider Demographics
NPI:1164129177
Name:MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Entity Type:Organization
Organization Name:MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-334-8781
Mailing Address - Street 1:230 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-2320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:LYNNFIELD
Practice Address - State:MA
Practice Address - Zip Code:01940-2320
Practice Address - Country:US
Practice Address - Phone:781-334-8781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder