=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477187805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW AVIV, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2020
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 BOSTON POST RD
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02493-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-284-8639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 EVERETT ST
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-523-8190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | CHRISTOPHER DIDDLE
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 561-523-8190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------