Healthcare Provider Details

I. General information

NPI: 1982838751
Provider Name (Legal Business Name): WEDIKO CHILDREN'S SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 E DEDHAM ST
BOSTON MA
02118-2315
US

IV. Provider business mailing address

72 E DEDHAM ST
BOSTON MA
02118-2315
US

V. Phone/Fax

Practice location:
  • Phone: 617-292-9200
  • Fax: 617-292-9272
Mailing address:
  • Phone: 617-292-9200
  • Fax: 617-292-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL CLONTZ
Title or Position: PROGRAM DIRECTOR
Credential: MSW
Phone: 617-292-9200