Provider Demographics
NPI:1205387727
Name:BEAVERBROOK STEP, INC.
Entity Type:Organization
Organization Name:BEAVERBROOK STEP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LMHC, LCSW
Authorized Official - Phone:617-926-1113
Mailing Address - Street 1:85 MAIN ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4411
Mailing Address - Country:US
Mailing Address - Phone:617-974-0148
Mailing Address - Fax:617-926-1227
Practice Address - Street 1:85 MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4411
Practice Address - Country:US
Practice Address - Phone:617-974-0148
Practice Address - Fax:617-926-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201069251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services