Basic Information
| Provider Information | |||||||||
| NPI: | 1184818197 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HABIT OPCO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 580 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018801253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174421499 | ||||||||
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| Practice Location | |||||||||
| Address1: | 99 TOPEKA ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174421499 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2007 | ||||||||
| LastUpdateDate: | 09/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | TERI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6174421499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.ED, LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.