Provider Demographics
NPI:1962786004
Name:EATING DISORDER CENTER OF ANDOVER, LLC
Entity type:Organization
Organization Name:EATING DISORDER CENTER OF ANDOVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:978-475-1617
Mailing Address - Street 1:68 MAIN ST
Mailing Address - Street 2:5
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:68 MAIN ST
Practice Address - Street 2:5
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3846
Practice Address - Country:US
Practice Address - Phone:978-475-1617
Practice Address - Fax:978-824-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1383106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty