Provider Demographics
NPI:1518387950
Name:BEHAVIORAL NUTRITION, INC.
Entity Type:Organization
Organization Name:BEHAVIORAL NUTRITION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, BEHAVIORAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:617-595-7044
Mailing Address - Street 1:1266 FURNACE BROOK PKWY
Mailing Address - Street 2:SUITE #404
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4758
Mailing Address - Country:US
Mailing Address - Phone:617-595-7044
Mailing Address - Fax:
Practice Address - Street 1:1266 FURNACE BROOK PKWY
Practice Address - Street 2:SUITE #404
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4758
Practice Address - Country:US
Practice Address - Phone:617-595-7044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3632133N00000X
MA86013220133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1851686455OtherBEHAVIORAL NUTRITION