Basic Information
| Provider Information | |||||||||
| NPI: | 1922174226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRE DEVELOPMENTAL SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTH SHORE INFANT TODDLER PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 103 JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815932727 | ||||||||
| FaxNumber: | 7815932542 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815932727 | ||||||||
| FaxNumber: | 7815932542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACTING EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7815932727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | MA | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | 1800566 | 05 | MA | MEDICAID | EI0022 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 000000021538 | 01 | MA | BMC HEALTHNET PLAN | OTHER | 612070 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER | 0008021 | 01 | MA | NEIGHBORHOOD NHM & NHP | OTHER | 7903218 | 01 | MA | AETNA USH | OTHER | 36547 | 01 | MA | FALLON HEALTH PLAN | OTHER | 996264 | 01 | MA | NETWORK HEALTH PLAN | OTHER | 716096 | 01 | MA | TUFTS | OTHER |