Healthcare Provider Details

I. General information

NPI: 1205307576
Provider Name (Legal Business Name): TEEN CHALLENGE NEW ENGLAND INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 MAIN ST
BROCKTON MA
02301-7109
US

IV. Provider business mailing address

1311 MAIN ST
BROCKTON MA
02301-7109
US

V. Phone/Fax

Practice location:
  • Phone: 508-408-4378
  • Fax:
Mailing address:
  • Phone: 508-408-4378
  • Fax: 508-825-3242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEROME POSEY
Title or Position: PROGRAM DIRECTOR
Credential: M.ED, LADCI
Phone: 617-792-0581