Provider Demographics
NPI:1639564214
Name:NORTHEAST BEHAVIORAL ASSOCIATES
Entity Type:Organization
Organization Name:NORTHEAST BEHAVIORAL ASSOCIATES
Other - Org Name:NORTHEAST BEHAVIORAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BEHAVIORAL MANAGEMENT THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAYLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:774-240-1504
Mailing Address - Street 1:23 DAILEY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2250
Mailing Address - Country:US
Mailing Address - Phone:774-240-1504
Mailing Address - Fax:
Practice Address - Street 1:23 DAILEY RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2250
Practice Address - Country:US
Practice Address - Phone:774-240-1504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness