Healthcare Provider Details

I. General information

NPI: 1619181880
Provider Name (Legal Business Name): NORTHEASTERN UNIVERSITY, UNIVERSITY HEALTH & COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 FORSYTH ST 360 HUNTINGTON AVE.
BOSTON MA
02115-5024
US

IV. Provider business mailing address

1 ABERDEEN WAY UNIT 206
CAMBRIDGE MA
02138-4626
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-2772
  • Fax:
Mailing address:
  • Phone: 617-492-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number254638
License Number StateMA

VIII. Authorized Official

Name: GAIRY F. HALL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 617-373-7523