Basic Information
| Provider Information | |||||||||
| NPI: | 1649449778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARVARD VANGUARD MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 GROVE ST | ||||||||
| Address2: | SUITE 3-300 | ||||||||
| City: | AUBURNDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024662272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 WALL ST | ||||||||
| Address2: | BEHAVIORAL HEALTH DEPT | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | LINDSEY | ||||||||
| AuthorizedOfficialFirstName: | H. EUGENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175598374 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 364SP0807X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 669493 | 01 | MA | TUFTS | OTHER |