Healthcare Provider Details

I. General information

NPI: 1396097309
Provider Name (Legal Business Name): THE VILLAGE-CHILD & FAMILY DEVELOPMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ADAMS ST
BRAINTREE MA
02184-1911
US

IV. Provider business mailing address

28 SHADE ST
RANDOLPH MA
02368-1769
US

V. Phone/Fax

Practice location:
  • Phone: 781-269-2323
  • Fax:
Mailing address:
  • Phone: 781-269-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number11745
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number19782
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6919
License Number StateMA

VIII. Authorized Official

Name: MS. CASSANDRA A CLARK
Title or Position: OWNER
Credential: MS, OTR/L
Phone: 781-269-2323