Healthcare Provider Details

I. General information

NPI: 1952823239
Provider Name (Legal Business Name): ALEXANDRA DIAMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2017
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WARREN ST
BRIGHTON MA
02135
US

IV. Provider business mailing address

460 HARRISON AVE UNIT 211B
BOSTON MA
02118-2785
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-3800
  • Fax:
Mailing address:
  • Phone: 239-292-1912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: