MEDICARE: CROSSROAD COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1245111350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROAD COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	257 MYRTLE STREET EXT STE A
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-5871
Country	:	US
Telephone Number	:	857-258-5479
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 HARRISON AVE STE A
Second Line	:
City	:	ROXBURY
State	:	MA
Zip	:	02119-3665
Country	:	US
Telephone Number	:	857-237-5167
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DONNIECE WATSON
Credential	:	LMHC
Telephone Number	:	857-258-5479

Provider Enumeration Date	:	09/08/2025
Last Update Date	:	09/08/2025

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