Healthcare Provider Details

I. General information

NPI: 1205066222
Provider Name (Legal Business Name): NORTHEASTERN UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 LEON ST 503 BEHRAKIS HEALTH SCIENCES CENTER
BOSTON MA
02115-5009
US

IV. Provider business mailing address

30 LEON ST 503 BEHRAKIS HEALTH SCIENCES CENTER
BOSTON MA
02115-5009
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-2492
  • Fax: 671-373-8756
Mailing address:
  • Phone: 617-373-2492
  • Fax: 671-373-8756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number4AKD
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4AKD
License Number StateMA

VIII. Authorized Official

Name: MR. SAMUEL B SOLOMON
Title or Position: DIRECTOR OF FINANCE AND TREASURER
Credential:
Phone: 617-373-2597