Provider Demographics
NPI:1730510314
Name:STANLEY, CALVIN (M ED)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-3415
Mailing Address - Country:US
Mailing Address - Phone:781-228-0145
Mailing Address - Fax:
Practice Address - Street 1:23 MARSTON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4444
Practice Address - Country:US
Practice Address - Phone:781-437-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1607103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265Medicaid