Healthcare Provider Details

I. General information

NPI: 1316368749
Provider Name (Legal Business Name): TRIAD ADOLESCENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 MASS AVE SUITE 204
LEXINGTON MA
02420
US

IV. Provider business mailing address

363 MASS AVE SUITE 204
LEXINGTON MA
02420
US

V. Phone/Fax

Practice location:
  • Phone: 781-864-4814
  • Fax:
Mailing address:
  • Phone: 781-864-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2353
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number9159
License Number StateMA

VIII. Authorized Official

Name: DR. GILLIAN CAROL GALEN
Title or Position: CLINICAL DIRECTOR
Credential: PSYD
Phone: 617-290-9432