Healthcare Provider Details

I. General information

NPI: 1780115519
Provider Name (Legal Business Name): SUPPORTIVE BEHAVIORAL CARE OF MA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 SCHOOL ST SUITE 325
BOSTON MA
02108-4201
US

IV. Provider business mailing address

14 SHEMEN ST
LAKEWOOD NJ
08701-3662
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-4375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: RAPHAEL LICHTSCHEIN
Title or Position: PRESIDENT
Credential:
Phone: 718-298-4375