Healthcare Provider Details

I. General information

NPI: 1902952658
Provider Name (Legal Business Name): CHILD DEVELOPMENT NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BEDFORD ST STE 12
LEXINGTON MA
02420-4640
US

IV. Provider business mailing address

76 BEDFORD ST STE 12
LEXINGTON MA
02420-4640
US

V. Phone/Fax

Practice location:
  • Phone: 781-861-6655
  • Fax: 781-861-6654
Mailing address:
  • Phone: 781-861-6655
  • Fax: 781-861-6654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JANINE KORAHAIS STASIOR
Title or Position: NEUROPSYCHOLOGIST, BUSINESS OWNER
Credential: PHD, MS
Phone: 781-861-6655