Healthcare Provider Details

I. General information

NPI: 1023806775
Provider Name (Legal Business Name): ROSCOE M. HURLEY LADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WHITE ST
EAST BOSTON MA
02128-5129
US

IV. Provider business mailing address

25 WHITE ST
EAST BOSTON MA
02128-5129
US

V. Phone/Fax

Practice location:
  • Phone: 617-447-1766
  • Fax:
Mailing address:
  • Phone: 617-447-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13663
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: