Provider Demographics
NPI:1265828768
Name:ITALIAN HOME FOR CHILDREN
Entity Type:Organization
Organization Name:ITALIAN HOME FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR STAFF ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-524-3116
Mailing Address - Street 1:1125 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3445
Mailing Address - Country:US
Mailing Address - Phone:617-524-3116
Mailing Address - Fax:
Practice Address - Street 1:77B WARREN STREET
Practice Address - Street 2:BUILDING 2
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-787-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1475185320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1063549962Medicaid
MA1922043876Medicaid