Healthcare Provider Details

I. General information

NPI: 1396620266
Provider Name (Legal Business Name): INTEGRATED CENTER FOR CHILD DEVELOPMENT COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 OAK ST STE G10
NEWTON UPPER FALLS MA
02464-1492
US

IV. Provider business mailing address

340 TURNPIKE ST STE 1-3A
CANTON MA
02021-2700
US

V. Phone/Fax

Practice location:
  • Phone: 781-619-1500
  • Fax: 781-619-1509
Mailing address:
  • Phone: 781-619-1516
  • Fax: 781-619-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHY FEHILY
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 781-619-1516