Healthcare Provider Details

I. General information

NPI: 1528294832
Provider Name (Legal Business Name): TOWARD INDEPENDENT LIVING AND LEARNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 EASTBROOK RD SUITE 201
DEDHAM MA
02026-2075
US

IV. Provider business mailing address

20 EASTBROOK RD SUITE 201
DEDHAM MA
02026-2075
US

V. Phone/Fax

Practice location:
  • Phone: 781-302-4600
  • Fax:
Mailing address:
  • Phone: 781-302-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number73077
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number199217
License Number StateMA

VIII. Authorized Official

Name: DAFNA KROUK-GORDON
Title or Position: PRESIDENT
Credential:
Phone: 781-302-4600