Provider Demographics
NPI:1306087457
Name:BOSTON BEHAVIORAL MEDICINE, LLC
Entity type:Organization
Organization Name:BOSTON BEHAVIORAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-232-2435
Mailing Address - Street 1:1371 BEACON ST STE 304
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4905
Mailing Address - Country:US
Mailing Address - Phone:617-232-2435
Mailing Address - Fax:617-232-0078
Practice Address - Street 1:1371 BEACON ST STE 304
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4905
Practice Address - Country:US
Practice Address - Phone:617-232-2435
Practice Address - Fax:617-232-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181401364SP0809X
MA7454103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA791373OtherTUFTS HEALTH INSURANCE
IP574730OtherMEGELLAN
0000PN0601OtherBLUE CROSS BLUE SHIELD LEGACY NUMBER
0000WO6099OtherBLUE CROSS BLUE SHIELD LEGACY NUMBER
MA1030430OtherBEACON HEALTH STRATEGIES
MA1893165Medicaid
MALAW51023OtherMEDICARE
MA1093165OtherMBHP
MA1790817732OtherNPI
MA1003850330OtherNPI
MA461385OtherTUFTS HEALTH INSURANCE