Basic Information
Provider Information | |||||||||
NPI: | 1982137196 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERVICK | ||||||||
FirstName: | TARA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 227 CHELMSFORD ST | ||||||||
Address2: |   | ||||||||
City: | CHELMSFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 018242305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9787327171 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 BURLINGTON RD | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017301406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7818623600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2017 | ||||||||
LastUpdateDate: | 12/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   | MA | N |   |   |   |   | 103K00000X | 3467-MH-B1 | MA | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 042611055 | 01 | MA | TAX ID | OTHER | 1004745 | 01 | MA | NHP | OTHER | 1303287 | 01 | MA | MBHP | OTHER | M18633 | 01 | MA | BCBS | OTHER | 1004745 | 01 | MA | FALLON | OTHER | 0000023532 | 01 | MA | BMC | OTHER | 99618201 | 01 | MA | NETWORK HEALTH | OTHER |