Provider Demographics
NPI:1518164508
Name:THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN
Entity Type:Organization
Organization Name:THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN
Other - Org Name:THE COUNSELING CENTER OF CHILD DEVELOPMENT AND EDUCATION, INC./CHILD D
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:B
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:781-393-5150
Mailing Address - Street 1:10 CABOT ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-393-5150
Mailing Address - Fax:781-393-5169
Practice Address - Street 1:10 CABOT ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:718-393-5150
Practice Address - Fax:781-393-5169
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILD DEVELOPMENT AND EDUCATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-02
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA404J1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1518164508OtherMBHP
MA1518164508OtherFALLON COMMUNITY HEALTH PLAN
MA963959-01OtherNETWORK
MA288472OtherTUFTS HEALTH PLAN
MA1031830OtherBEACON HEALTH STRATEGIES (NHP)
MA1518164508OtherBEACON (BMC)
MA110081507BMedicaid
MA0015666OtherMEDICARE
MA1518164508OtherBLUE CROSS/BLUE SHIELD