Healthcare Provider Details

I. General information

NPI: 1699930370
Provider Name (Legal Business Name): INDIVIDUAL AND FAMILY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SILVER STREET 106
AGAWAM MA
01001-1647
US

IV. Provider business mailing address

200 SILVER STREET 106
AGAWAM MA
01001-1647
US

V. Phone/Fax

Practice location:
  • Phone: 413-789-9198
  • Fax: 413-789-6322
Mailing address:
  • Phone: 413-789-9198
  • Fax: 413-789-6322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number106947
License Number StateMA

VIII. Authorized Official

Name: MRS. CRISTINA DI NARDO-DUPRE
Title or Position: SOCIAL WORKER/OWNER
Credential: LICSW
Phone: 413-789-9198