Healthcare Provider Details

I. General information

NPI: 1649759770
Provider Name (Legal Business Name): SUMMIT ACADEMY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 JAMESBURY DR
WORCESTER MA
01609-1201
US

IV. Provider business mailing address

15 JAMESBURY DR
WORCESTER MA
01609-1201
US

V. Phone/Fax

Practice location:
  • Phone: 508-751-8500
  • Fax: 508-751-8501
Mailing address:
  • Phone: 508-751-8500
  • Fax: 508-751-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL JAMES DIMEZZA
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential:
Phone: 508-751-8500