Healthcare Provider Details

I. General information

NPI: 1205228111
Provider Name (Legal Business Name): COBBLESTONES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 RIVER ST
WALTHAM MA
02453-8300
US

IV. Provider business mailing address

85 RIVER ST
WALTHAM MA
02453-8300
US

V. Phone/Fax

Practice location:
  • Phone: 781-609-2514
  • Fax:
Mailing address:
  • Phone: 781-609-2514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE CROAK
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 781-609-2514