Healthcare Provider Details

I. General information

NPI: 1205365509
Provider Name (Legal Business Name): MARLBOROUGH COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MECHANIC ST STE 300
MARLBOROUGH MA
01752-4425
US

IV. Provider business mailing address

40 MECHANIC ST STE 300
MARLBOROUGH MA
01752-4425
US

V. Phone/Fax

Practice location:
  • Phone: 508-658-0880
  • Fax: 508-597-7772
Mailing address:
  • Phone: 508-658-0880
  • Fax: 508-597-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. LYNN K. FAUST
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 508-658-0880