Provider Demographics
NPI:1891780144
Name:BOURNEWOOD CLINICAL ASSOCIATES
Entity type:Organization
Organization Name:BOURNEWOOD CLINICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-469-0300
Mailing Address - Street 1:300 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3658
Mailing Address - Country:US
Mailing Address - Phone:617-469-0300
Mailing Address - Fax:617-469-5013
Practice Address - Street 1:300 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02467-3658
Practice Address - Country:US
Practice Address - Phone:617-469-0300
Practice Address - Fax:617-469-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773908Medicaid
MAM15391OtherBLUE SHIELD PROVIDER NUMB
MA9773908Medicaid