Provider Demographics
NPI:1144488990
Name:THE HOME FOR LITTLE WANDERERS
Entity type:Organization
Organization Name:THE HOME FOR LITTLE WANDERERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STARR CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:508-668-7703
Mailing Address - Street 1:399 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1218
Mailing Address - Country:US
Mailing Address - Phone:508-668-7703
Mailing Address - Fax:508-660-9639
Practice Address - Street 1:399 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1218
Practice Address - Country:US
Practice Address - Phone:508-668-7703
Practice Address - Fax:508-660-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========4Medicaid