Healthcare Provider Details

I. General information

NPI: 1902141179
Provider Name (Legal Business Name): EAST SIDE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 BEDFORD ST
FALL RIVER MA
02723-2637
US

IV. Provider business mailing address

1311 BEDFORD ST.
FALL RIVE, MA MA
02723
US

V. Phone/Fax

Practice location:
  • Phone: 508-567-1477
  • Fax: 508-567-6494
Mailing address:
  • Phone: 508-567-1477
  • Fax: 598-567-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1028438
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. MARY R. CRUZ
Title or Position: MANAGER
Credential: LICSW
Phone: 508-567-1477