Basic Information
| Provider Information | |||||||||
| NPI: | 1861611592 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNSELING & PSYCHOTHERAPY CENTER OF GREATER BOSTON, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE COUNSELING & PSYCHOTHERAPY CENTER, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 687 HIGHLAND AVE | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024942232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004558726 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 687 HIGHLAND AVE | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004558726 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | APP | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 8004558726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ISW01363 | RI | N | Agencies | Community/Behavioral Health | 251S00000X | MA100144 | MA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 153410000 | 05 | ME | MEDICAID | 431882600 | 05 | ME | MEDICAID | TC18547 | 05 | RI | MEDICAID | 1022840 | 05 | RI | MEDICAID |