Healthcare Provider Details

I. General information

NPI: 1114979580
Provider Name (Legal Business Name): THE MCLEAN HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST
BELMONT MA
02478-1041
US

IV. Provider business mailing address

P.O. BOX 5-0397
WOBURN MA
01815-0397
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2183
  • Fax: 617-855-3745
Mailing address:
  • Phone: 617-855-2183
  • Fax: 617-855-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH GOLD
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 617-855-2367