Provider Demographics
NPI:1922880137
Name:MIELJADE BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:MIELJADE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GIFTY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMPAW
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, BCBA, LABA
Authorized Official - Phone:774-420-8760
Mailing Address - Street 1:11 APEX DRIVE, SUITE 300A, #110
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1623
Mailing Address - Country:US
Mailing Address - Phone:508-456-9590
Mailing Address - Fax:
Practice Address - Street 1:26 UTICA DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1623
Practice Address - Country:US
Practice Address - Phone:774-420-8760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty