Basic Information
| Provider Information | |||||||||
| NPI: | 1881283091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FBTC TRANSITIONAL SUB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 TOZER RD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019155515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789692894 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 TOZER RD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019155515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789692894 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6176426271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.ED | ||||||||
| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 110078808A | 05 | MA | MEDICAID |