Basic Information
| Provider Information | |||||||||
| NPI: | 1528294832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOWARD INDEPENDENT LIVING AND LEARNING | ||||||||
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| OtherOrganizationName: | TILL MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 EASTBROOK RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020262075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813024600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 EASTBROOK RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020262075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813024600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 06/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | KROUK-GORDON | ||||||||
| AuthorizedOfficialFirstName: | DAFNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7813024600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 199217 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 2084N0400X | 73077 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.