Healthcare Provider Details

I. General information

NPI: 1558814129
Provider Name (Legal Business Name): IMARI ROCHELL MEDEIROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IMARI ROCHELL GONZALEZ LICSW

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date: 01/06/2022
Reactivation Date: 02/03/2022

III. Provider practice location address

27 CENTRAL SQ # 1008
BRIDGEWATER MA
02324-2508
US

IV. Provider business mailing address

27 CENTRAL SQ # 1008
BRIDGEWATER MA
02324-2508
US

V. Phone/Fax

Practice location:
  • Phone: 508-685-8751
  • Fax: 508-463-9994
Mailing address:
  • Phone: 508-233-3327
  • Fax: 508-463-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number125732
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: