Provider Demographics
NPI:1649516220
Name:TEENS AGAINST GANG VIOLENCE
Entity type:Organization
Organization Name:TEENS AGAINST GANG VIOLENCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ULRIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LMFT, LADCI RC
Authorized Official - Phone:6173-365-0637
Mailing Address - Street 1:2 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3507
Mailing Address - Country:US
Mailing Address - Phone:617-365-0637
Mailing Address - Fax:617-282-9659
Practice Address - Street 1:735 MORRISSEY BLVD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02122-3406
Practice Address - Country:US
Practice Address - Phone:617-365-0637
Practice Address - Fax:617-282-9659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA265101YM0800X
MA149106H00000X
MA40101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty