Basic Information
| Provider Information | |||||||||
| NPI: | 1649356841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRANCISCAN HOSPITAL FOR CHILDREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172543800 | ||||||||
| FaxNumber: | 6177791262 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172543800 | ||||||||
| FaxNumber: | 6177791262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | MULLIN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, STAFF PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6172543800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6556 | MA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1200925 | 05 | MA | MEDICAID |