THE COMMONWEALTH CENTER FOR PSYCHOTHERAPY PC

Provider Demographics

• NPI: 1225062458
• Name: THE COMMONWEALTH CENTER FOR PSYCHOTHERAPY PC
• Entity Type: Organization
• Organization Name: THE COMMONWEALTH CENTER FOR PSYCHOTHERAPY PC
• Authorized Official - Title/Position: BILLING MANAGER
• Authorized Official - Prefix: MS
• Authorized Official - First Name: CYNTHIA
• Authorized Official - Last Name: KING
• Authorized Official - Phone: 781-828-1222
• Mailing Address - Street 1: 345 NEPONSET STREET
• Mailing Address - City: CANTON
• Mailing Address - State: MA
• Mailing Address - Zip Code: 02021
• Mailing Address - Country: US
• Mailing Address - Phone: 781-828-1222
• Mailing Address - Fax: 781-828-5454
• Practice Address - Street 1: 345 NEPONSET STREET
• Practice Address - City: CANTON
• Practice Address - State: MA
• Practice Address - Zip Code: 02021
• Practice Address - Country: US
• Practice Address - Phone: 781-828-1222
• Practice Address - Fax: 781-828-5454
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-07-11
• Last Update Date: 2008-01-31

Provider Licenses

State	License ID	Taxonomies
MA	573829	103T00000X
MA	6583	103T00000X
MA	1021865	104100000X
MA	1023877	104100000X
MA	110270	104100000X
MA	111432	104100000X
MA	110617	104100000X
MA	57414	2084P0804X
MA	154124	364SP0808X
MA	149491	364SP0808X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	104100000X	Behavioral Health & Social Service Providers	Social Worker		Group - Multi-Specialty
No	2084P0804X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Child & Adolescent Psychiatry	Group - Multi-Specialty
No	364SP0808X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist	Psychiatric/Mental Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	110617	Other	TUFTS DIRUHI
	469165	Other	TUFTS JENNIFER
	J16493	Other	BCBS RUSS
	350549	Other	TUFTS PAMELA
	P08335	Other	BCBS PAMELA
	409492	Other	TUFTS CHRIS
	461191	Other	TUFTS DLANE
	798610	Other	TUFTS LAURA
	799214	Other	TUFTS NETTIE
	P07650	Other	BCBS CHRIS
	W05659	Other	BCBS NETTIE
	P07809	Other	BCBS DIRUHI
	PN0784	Other	BCBS ELYSE
	154124	Other	TUFTS ELYSE
	RN0777	Other	BCBS DLANE
	57414	Other	TUFTS RUSS
	P06481	Other	BCBS ROSELLE
	P08363	Other	BCBS JENNIFER
	W05804	Other	BCBS LAURA
	469165	Other	TUFTS JENNIFER