Provider Demographics
NPI:1881806750
Name:MYSTIC LEARNING CENTER, INC.
Entity type:Organization
Organization Name:MYSTIC LEARNING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BERGMANN
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR OF ARTS
Authorized Official - Phone:617-623-0110
Mailing Address - Street 1:530 MYSTIC AVENUE ROOM 103
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1602
Mailing Address - Country:US
Mailing Address - Phone:617-623-0110
Mailing Address - Fax:617-623-4750
Practice Address - Street 1:530 MYSTIC AVENUE ROOM 103
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1602
Practice Address - Country:US
Practice Address - Phone:617-623-0110
Practice Address - Fax:617-623-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1221890251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable