Basic Information
Provider Information
NPI: 1003149972
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAECHEL
FirstName: COREY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PSYD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 60 KENDRICK ST
Address2: SUITE 204
City: NEEDHAM
State: MA
PostalCode: 024942726
CountryCode: US
TelephoneNumber: 8003703651
FaxNumber:  
Practice Location
Address1: 26 BEACON ST
Address2: APT 47A
City: BURLINGTON
State: MA
PostalCode: 018033803
CountryCode: US
TelephoneNumber: 6172515867
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/10/2009
LastUpdateDate: 11/18/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700X9989MAY Behavioral Health & Social Service ProvidersPsychologistClinical
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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