Provider Demographics
NPI:1518043587
Name:BOSTONNEUROBEHAVIORALASSOCIATES
Entity Type:Organization
Organization Name:BOSTONNEUROBEHAVIORALASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOROFOUTPATIENTSERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:1781-492-1689
Mailing Address - Street 1:80 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1765
Mailing Address - Country:US
Mailing Address - Phone:781-492-1689
Mailing Address - Fax:
Practice Address - Street 1:80 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1765
Practice Address - Country:US
Practice Address - Phone:781-492-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA974608Medicaid
MA974608Medicaid