Healthcare Provider Details

I. General information

NPI: 1417877994
Provider Name (Legal Business Name): ANDREW JOHN SOUTHCOTT MST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 THOREAU ST
CONCORD MA
01742-2411
US

IV. Provider business mailing address

42 THOREAU ST
CONCORD MA
01742-2411
US

V. Phone/Fax

Practice location:
  • Phone: 978-314-8922
  • Fax:
Mailing address:
  • Phone: 978-314-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3058
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: