Healthcare Provider Details

I. General information

NPI: 1215568845
Provider Name (Legal Business Name): MARISSA LYNN VACHON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2020
Last Update Date: 02/02/2020
Certification Date: 02/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 FORDHAM RD
ALLSTON MA
02134-3000
US

IV. Provider business mailing address

220 FRANKLIN ST
MELROSE MA
02176-1823
US

V. Phone/Fax

Practice location:
  • Phone: 617-782-6460
  • Fax:
Mailing address:
  • Phone: 603-856-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: