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General NPI Number Information
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NPI Number | 1518164508
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Entity Type | Organization
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Legal Business Name | THE COUNSELING CENTER OF CHILD DEVELOPMENT, IN
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 06/01/2012
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Provider Practice Location Address
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Address Line | 10 CABOT ROAD SUITE 101
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City | MEDFORD
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State | MA
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Zip | 02155
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Country | US
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Telephone | 718-393-5150
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Fax | 781-393-5169
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Provider Business Mailing Address
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Address Line | 10 CABOT ROAD SUITE 101
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City | MEDFORD
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State | MA
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Zip | 02155
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Country | US
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Telephone | 781-393-5150
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Fax | 781-393-5169
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | ANN B. FITZGERALD
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Credential | LICSW
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Telephone | 781-393-5150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 404J
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License Number State | MA
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