Provider Demographics
NPI:1205307576
Name:TEEN CHALLENGE NEW ENGLAND INC
Entity type:Organization
Organization Name:TEEN CHALLENGE NEW ENGLAND INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:POSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LADCI
Authorized Official - Phone:617-792-0581
Mailing Address - Street 1:1311 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7109
Mailing Address - Country:US
Mailing Address - Phone:508-408-4378
Mailing Address - Fax:508-825-3242
Practice Address - Street 1:1311 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7109
Practice Address - Country:US
Practice Address - Phone:508-408-4378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110158884AMedicaid