Provider Demographics
NPI:1871136275
Name:BOSTON TRAUMA THERAPY, LLC
Entity type:Organization
Organization Name:BOSTON TRAUMA THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNESTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-420-5258
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-0003
Mailing Address - Country:US
Mailing Address - Phone:617-420-5258
Mailing Address - Fax:
Practice Address - Street 1:224 CLARENDON ST STE 51
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3793
Practice Address - Country:US
Practice Address - Phone:617-420-5258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty