Healthcare Provider Details

I. General information

NPI: 1508197104
Provider Name (Legal Business Name): STACEY MCENERNEY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72-74 EAST DEDHAM ST.
BOSTON MA
02118
US

IV. Provider business mailing address

72-74 EAST DEDHAM ST.
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-292-9200
  • Fax: 617-292-9275
Mailing address:
  • Phone: 617-292-9200
  • Fax: 617-292-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH4755CC
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: