Basic Information
| Provider Information | |||||||||
| NPI: | 1366598310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROJECT CHILLD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CUMMINGS CTR | ||||||||
| Address2: | SUITE 3850 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782320332 | ||||||||
| FaxNumber: | 9782321103 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CUMMINGS CTR | ||||||||
| Address2: | SUITE 3850 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782320332 | ||||||||
| FaxNumber: | 9782321103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARLEY | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER-DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9782320332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S. O.T.R. L. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OG0033 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |