Healthcare Provider Details

I. General information

NPI: 1417776774
Provider Name (Legal Business Name): RECREATIONAL BEHAVIOR THERAPY AND RESPITE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 WASHINGTON ST # 287
WELLESLEY MA
02481-6209
US

IV. Provider business mailing address

396 WASHINGTON ST # 287
WELLESLEY MA
02481-6209
US

V. Phone/Fax

Practice location:
  • Phone: 802-355-7369
  • Fax:
Mailing address:
  • Phone: 781-650-7287
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: ALFRED JOHN FRUGOLI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 781-650-5172