Provider Demographics
NPI:1902952658
Name:CHILD DEVELOPMENT NETWORK
Entity Type:Organization
Organization Name:CHILD DEVELOPMENT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST, BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:KORAHAIS
Authorized Official - Last Name:STASIOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MS
Authorized Official - Phone:781-861-6655
Mailing Address - Street 1:76 BEDFORD ST STE 12
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4640
Mailing Address - Country:US
Mailing Address - Phone:781-861-6655
Mailing Address - Fax:781-861-6654
Practice Address - Street 1:76 BEDFORD ST STE 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4640
Practice Address - Country:US
Practice Address - Phone:781-861-6655
Practice Address - Fax:781-861-6654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW10652OtherBLUE CROSS BLUE SHIELD