Provider Demographics
NPI:1780995332
Name:BOSTON BEHAVIOR THERAPY LLC
Entity type:Organization
Organization Name:BOSTON BEHAVIOR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERMERWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-580-2337
Mailing Address - Street 1:300 TRADE CENTER 100 SYLVAN RD
Mailing Address - Street 2:SUITE 7790
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1883
Mailing Address - Country:US
Mailing Address - Phone:781-281-0213
Mailing Address - Fax:781-281-0764
Practice Address - Street 1:300 TRADE CENTER 100 SYLVAN RD
Practice Address - Street 2:SUITE 7790
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1883
Practice Address - Country:US
Practice Address - Phone:781-281-0213
Practice Address - Fax:781-281-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4233103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1124356233OtherSOLO NPI
MA1104053933OtherSOLO NPI