Provider Demographics
NPI:1518246131
Name:BOSTON PSYCHIATRIC CARE LLC
Entity Type:Organization
Organization Name:BOSTON PSYCHIATRIC CARE LLC
Other - Org Name:BOSTON PSYCHIATRIC CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL NURSE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FEDOROV
Authorized Official - Suffix:
Authorized Official - Credentials:RN CNS
Authorized Official - Phone:617-830-1644
Mailing Address - Street 1:11 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2588
Mailing Address - Country:US
Mailing Address - Phone:617-830-1644
Mailing Address - Fax:617-830-1644
Practice Address - Street 1:11 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2588
Practice Address - Country:US
Practice Address - Phone:617-830-1644
Practice Address - Fax:617-830-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA271091261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1811189210OtherINDIVIDUAL NPI NUMBER FOR DANIELLE MARIE FEDOROV RN CNS