Healthcare Provider Details

I. General information

NPI: 1851171219
Provider Name (Legal Business Name): MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 GRANITE ST STE 402
BRAINTREE MA
02184-5369
US

IV. Provider business mailing address

639 GRANITE ST STE 402
BRAINTREE MA
02184-5369
US

V. Phone/Fax

Practice location:
  • Phone: 603-703-2545
  • Fax:
Mailing address:
  • Phone: 603-703-2545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD THATCHER
Title or Position: CFO
Credential:
Phone: 754-217-8127