Healthcare Provider Details

I. General information

NPI: 1205298932
Provider Name (Legal Business Name): PRIDESTAR CENTER FOR APPLIED LEARNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 STEDMAN ST
LOWELL MA
01851-2705
US

IV. Provider business mailing address

229 STEDMAN ST
LOWELL MA
01851-2705
US

V. Phone/Fax

Practice location:
  • Phone: 978-677-6952
  • Fax:
Mailing address:
  • Phone: 978-677-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number00123
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number00123
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number00123
License Number StateMA

VIII. Authorized Official

Name: MS. LYN ANN SNOW
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA/LABA
Phone: 978-677-6952