Healthcare Provider Details

I. General information

NPI: 1164129177
Provider Name (Legal Business Name): MASSACHUSETTS CENTER FOR ADOLESCENT WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 BROADWAY STE 201
LYNNFIELD MA
01940-2320
US

IV. Provider business mailing address

230 BROADWAY STE 201
LYNNFIELD MA
01940-2320
US

V. Phone/Fax

Practice location:
  • Phone: 781-334-8781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ED THATCHER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 754-217-8127