Healthcare Provider Details

I. General information

NPI: 1265645261
Provider Name (Legal Business Name): ACADEMIC & BEHAVIORAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 BLUE HILL AVE
DORCHESTER CENTER MA
02124-2828
US

IV. Provider business mailing address

PO BOX 190789
BOSTON MA
02119-0015
US

V. Phone/Fax

Practice location:
  • Phone: 617-822-0829
  • Fax: 617-825-7804
Mailing address:
  • Phone: 617-822-0829
  • Fax: 617-825-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4D1R
License Number StateMA

VIII. Authorized Official

Name: DR. TERRI BETTS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 617-822-0829