Provider Demographics
NPI:1851171219
Name:MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Entity Type:Organization
Organization Name:MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:THATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-217-8127
Mailing Address - Street 1:639 GRANITE ST STE 402
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5369
Mailing Address - Country:US
Mailing Address - Phone:603-703-2545
Mailing Address - Fax:
Practice Address - Street 1:639 GRANITE ST STE 402
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5369
Practice Address - Country:US
Practice Address - Phone:603-703-2545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder