Healthcare Provider Details

I. General information

NPI: 1336037829
Provider Name (Legal Business Name): ZIJIAN QIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BOSTON AVE STE 1925
MEDFORD MA
02155-4243
US

IV. Provider business mailing address

55 WHEELER ST UNIT APTB634
CAMBRIDGE MA
02138-1192
US

V. Phone/Fax

Practice location:
  • Phone: 812-606-1444
  • Fax:
Mailing address:
  • Phone: 812-606-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: