Provider Demographics
NPI:1619007630
Name:AGESPAN, INC.
Entity Type:Organization
Organization Name:AGESPAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HATEM-ROY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:978-683-7747
Mailing Address - Street 1:280 MERRIMACK ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1779
Mailing Address - Country:US
Mailing Address - Phone:978-683-7747
Mailing Address - Fax:978-687-1067
Practice Address - Street 1:280 MERRIMACK ST
Practice Address - Street 2:SUITE 400
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843
Practice Address - Country:US
Practice Address - Phone:978-683-7747
Practice Address - Fax:978-687-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0603864OtherWAIVER