Provider Demographics
NPI:1477194793
Name:PEDIATRIC AND ADOLESCENT BEHAVIORAL
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-697-2282
Mailing Address - Street 1:86 WELLESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-6634
Mailing Address - Country:US
Mailing Address - Phone:617-697-2282
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH ST STE 200
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-1100
Practice Address - Country:US
Practice Address - Phone:617-697-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110120284AMedicaid