Provider Demographics
NPI:1265645261
Name:ACADEMIC & BEHAVIORAL CLINIC
Entity Type:Organization
Organization Name:ACADEMIC & BEHAVIORAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-822-0829
Mailing Address - Street 1:PO BOX 190789
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-0015
Mailing Address - Country:US
Mailing Address - Phone:617-822-0829
Mailing Address - Fax:617-825-7804
Practice Address - Street 1:995 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2828
Practice Address - Country:US
Practice Address - Phone:617-822-0829
Practice Address - Fax:617-825-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4D1R251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1073500OtherNEIGHBORHOOD HEALTH PLAN
MA1301462OtherMASSACHUSETTS BEHAVIORAL PARTNERSHIP
MAW10655OtherBLUE CROSS & BLUE SHIELD