Healthcare Provider Details

I. General information

NPI: 1174975452
Provider Name (Legal Business Name): FATHERS' UPLIFT FAMILY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SOUTHERN AVE
DORCHESTER MA
02124-2012
US

IV. Provider business mailing address

12 SOUTHERN AVE
DORCHESTER MA
02124-2012
US

V. Phone/Fax

Practice location:
  • Phone: 617-708-0870
  • Fax:
Mailing address:
  • Phone: 617-708-0870
  • Fax: 617-516-8274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119702
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. TATIANA CURTIS
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 617-798-1061