Provider Demographics
NPI:1215411376
Name:ANDOVER SOCIAL DEVELOPMENT AND COUNSELING CENTER
Entity Type:Organization
Organization Name:ANDOVER SOCIAL DEVELOPMENT AND COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROGERS-BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:978-077-1642
Mailing Address - Street 1:89 N MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3581
Mailing Address - Country:US
Mailing Address - Phone:978-771-6428
Mailing Address - Fax:
Practice Address - Street 1:89 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3581
Practice Address - Country:US
Practice Address - Phone:978-771-6428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1861910275Medicaid