Healthcare Provider Details

I. General information

NPI: 1306087457
Provider Name (Legal Business Name): BOSTON BEHAVIORAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 BEACON ST STE 304
BROOKLINE MA
02446-4905
US

IV. Provider business mailing address

1371 BEACON ST STE 304
BROOKLINE MA
02446-4905
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-2435
  • Fax: 617-232-0078
Mailing address:
  • Phone: 617-232-2435
  • Fax: 617-232-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number181401
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7454
License Number StateMA

VIII. Authorized Official

Name: DR. KATHARINE M LARSSON
Title or Position: CO-DIRECTOR
Credential: PHD
Phone: 617-232-2435