Healthcare Provider Details

I. General information

NPI: 1417942053
Provider Name (Legal Business Name): ANNE STACIE COLWELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACIE A COLWELL MD

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST SUITE 334 CENTER FOR CHILDREN WTH SPECIAL NEEDS
BOSTON MA
02111-1552
US

IV. Provider business mailing address

800 WASHINGTON ST CENTER FOR CHILDREN WITH SPECIAL NEEDS
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-7242
  • Fax: 617-636-7242
Mailing address:
  • Phone: 617-636-7242
  • Fax: 617-636-5621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042-0010725
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15974
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number254910
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: