Provider Demographics
NPI:1982838751
Name:WEDIKO CHILDREN'S SERVICES
Entity Type:Organization
Organization Name:WEDIKO CHILDREN'S SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:617-292-9200
Mailing Address - Street 1:72 E DEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2315
Mailing Address - Country:US
Mailing Address - Phone:617-292-9200
Mailing Address - Fax:617-292-9272
Practice Address - Street 1:72 E DEDHAM ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2315
Practice Address - Country:US
Practice Address - Phone:617-292-9200
Practice Address - Fax:617-292-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty