Healthcare Provider Details

I. General information

NPI: 1508409012
Provider Name (Legal Business Name): ALYSSA DEMOULAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 BOW ST
CAMBRIDGE MA
02138-5109
US

IV. Provider business mailing address

3 BOW ST
CAMBRIDGE MA
02138-5109
US

V. Phone/Fax

Practice location:
  • Phone: 617-547-2255
  • Fax: 617-547-0003
Mailing address:
  • Phone: 617-547-2255
  • Fax: 617-547-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11440
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: