Basic Information
| Provider Information | |||||||||
| NPI: | 1801932165 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HOME FOR LITTLE WANDERERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BOSTON EARLY INTERVENTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 HUNTINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021154506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172673700 | ||||||||
| FaxNumber: | 6174280441 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 BRIGHTON AVE | ||||||||
| Address2: | BUILDING #4 | ||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021342109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172541140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | NINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 6175857544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM3000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medically Fragile Intants and Children Day Care |
ID Information
| ID | Type | State | Issuer | Description | SCDPH36015005191 | 01 | MA | STATE CONTRACT NUMBER | OTHER | 1803182 | 05 | MA | MEDICAID |