Provider Demographics
NPI:1780115519
Name:SUPPORTIVE BEHAVIORAL CARE OF MA LLC
Entity type:Organization
Organization Name:SUPPORTIVE BEHAVIORAL CARE OF MA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTSCHEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-298-4375
Mailing Address - Street 1:14 SHEMEN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 SCHOOL ST
Practice Address - Street 2:SUITE 325
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4201
Practice Address - Country:US
Practice Address - Phone:718-298-4375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty