Provider Demographics
NPI:1851783419
Name:BABY TO BOOMER THERAPIES, LLC
Entity Type:Organization
Organization Name:BABY TO BOOMER THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS BACKERT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:347-307-0249
Mailing Address - Street 1:1661 MASSACHUSETTS AVE
Mailing Address - Street 2:UNITE 237
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-2020
Mailing Address - Country:US
Mailing Address - Phone:347-307-0249
Mailing Address - Fax:
Practice Address - Street 1:20 NORTH RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1057
Practice Address - Country:US
Practice Address - Phone:347-307-0249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty