Healthcare Provider Details

I. General information

NPI: 1720401979
Provider Name (Legal Business Name): INTEGRATED CENTER FOR CHILD DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 TURNPIKE ST
CANTON MA
02021-2700
US

IV. Provider business mailing address

340 TURNPIKE ST
CANTON MA
02021-2700
US

V. Phone/Fax

Practice location:
  • Phone: 781-619-1500
  • Fax: 617-527-0640
Mailing address:
  • Phone: 781-619-1500
  • Fax: 617-527-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10654
License Number StateMA

VIII. Authorized Official

Name: JULIE ROBINSON
Title or Position: DIRECTOR OF THERAPIES
Credential: OTR/L
Phone: 781-619-1581