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General NPI Number Information
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NPI Number | 1316368749
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Entity Type | Organization
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Legal Business Name | TRIAD ADOLESCENT SERVICES
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Dates
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Enumeration Date | 01/03/2014
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Last Update Date | 01/03/2014
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Provider Practice Location Address
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Address Line | 363 MASS AVE SUITE 204
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City | LEXINGTON
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State | MA
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Zip | 02420
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Country | US
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Telephone | 781-864-4814
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Fax |
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Provider Business Mailing Address
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Address Line | 363 MASS AVE SUITE 204
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City | LEXINGTON
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State | MA
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Zip | 02420
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Country | US
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Telephone | 781-864-4814
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. GILLIAN CAROL GALEN
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Credential | PSYD
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Telephone | 617-290-9432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 2353
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 9159
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License Number State | MA
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