MEDICARE: WEDIKO CHILDREN'S SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103TC2200X	Clinical Child & Adolescent Psychologist
2	1041C0700X	Clinical Social Worker
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1982838751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEDIKO CHILDREN'S SERVICES

Provider Business Mailing Address
First Line	:	72 E DEDHAM ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-2315
Country	:	US
Telephone Number	:	617-292-9200
Fax Number	:	617-292-9272

Provider Business Practice Location Address
First Line	:	72 E DEDHAM ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-2315
Country	:	US
Telephone Number	:	617-292-9200
Fax Number	:	617-292-9272

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MR. MICHAEL CLONTZ
Credential	:	MSW
Telephone Number	:	617-292-9200

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	06/08/2015

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