=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336493410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERKSHIRE COUNTY KIDS' PLACE AND VIOLENCE PREVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2012
-----------------------------------------------------
Last Update Date | 10/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 WENDELL AVENUE
-----------------------------------------------------
City | PITTSFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-499-2800
-----------------------------------------------------
Fax | 413-496-9327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 WENDELL AVENUE
-----------------------------------------------------
City | PITTSFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-499-2800
-----------------------------------------------------
Fax | 413-496-9327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL COORDINATOR
-----------------------------------------------------
Name | MS. JOANN OLIVER LYNCH
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 413-499-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------