Provider Demographics
NPI:1417942053
Name:COLWELL, ANNE STACIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:STACIE
Last Name:COLWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:A
Other - Last Name:COLWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:800 WASHINGTON ST
Mailing Address - Street 2:CENTER FOR CHILDREN WITH SPECIAL NEEDS
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-7242
Mailing Address - Fax:617-636-5621
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:SUITE 334 CENTER FOR CHILDREN WTH SPECIAL NEEDS
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-7242
Practice Address - Fax:617-636-7242
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010725208000000X
NH15974208000000X
MA254910208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010260Medicaid
VTVN3329Medicare ID - Type Unspecified
I02790Medicare UPIN