Provider Demographics
NPI:1861531725
Name:CITY OF PEABODY
Entity type:Organization
Organization Name:CITY OF PEABODY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MSG
Authorized Official - Phone:978-531-2254
Mailing Address - Street 1:79 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-4353
Mailing Address - Country:US
Mailing Address - Phone:978-531-2254
Mailing Address - Fax:978-531-7176
Practice Address - Street 1:79 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4353
Practice Address - Country:US
Practice Address - Phone:978-531-2254
Practice Address - Fax:978-531-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1902121Medicaid