Healthcare Provider Details

I. General information

NPI: 1528911773
Provider Name (Legal Business Name): PHOENIX DEVELOPMENTAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 BRIDLE PATH CIR
RANDOLPH MA
02368-4453
US

IV. Provider business mailing address

79 BRIDLE PATH CIR
RANDOLPH MA
02368-4453
US

V. Phone/Fax

Practice location:
  • Phone: 617-407-3666
  • Fax:
Mailing address:
  • Phone: 617-407-3666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT A GRIGORE
Title or Position: OWNER/CEO
Credential: BCBA
Phone: 617-407-3666