Healthcare Provider Details

I. General information

NPI: 1598052664
Provider Name (Legal Business Name): CLEGHORN PROFESSIONAL COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 FAIRMOUNT ST
FITCHBURG MA
01420-7613
US

IV. Provider business mailing address

63 FAIRMOUNT ST
FITCHBURG MA
01420-7613
US

V. Phone/Fax

Practice location:
  • Phone: 978-342-2709
  • Fax:
Mailing address:
  • Phone: 978-342-2709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7433
License Number StateMA

VIII. Authorized Official

Name: DENNIS ANTHONY BRADLEY
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 978-342-2709