Healthcare Provider Details

I. General information

NPI: 1124338124
Provider Name (Legal Business Name): ALA V KOZLENKO SHIELDS M. ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2010
Last Update Date: 10/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MORTON ST C/O HOPEFOUND MSTAB
JAMAICA PLAIN MA
02130-3735
US

IV. Provider business mailing address

170 MORTON ST C/O HOPEFOUND MSTAB
JAMAICA PLAIN MA
02130-3735
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-0351
  • Fax: 866-770-4430
Mailing address:
  • Phone: 617-983-0351
  • Fax: 866-770-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: