Healthcare Provider Details

I. General information

NPI: 1689554362
Provider Name (Legal Business Name): AFFECT PROVIDER GROUP P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CANAL ST STE 4
BOSTON MA
02114-2022
US

IV. Provider business mailing address

1640 BORO PL FL 4
MC LEAN VA
22102-3627
US

V. Phone/Fax

Practice location:
  • Phone: 845-769-8758
  • Fax:
Mailing address:
  • Phone: 845-760-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KARLA RENEE MULLINGS
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 845-768-8758