Healthcare Provider Details

I. General information

NPI: 1982893392
Provider Name (Legal Business Name): MIND OVER MATTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CRAWFORD ST
GARDNER MA
01440-3128
US

IV. Provider business mailing address

30 CRAWFORD ST
GARDNER MA
01440-3128
US

V. Phone/Fax

Practice location:
  • Phone: 978-660-0996
  • Fax:
Mailing address:
  • Phone: 978-660-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number114027
License Number StateMA

VIII. Authorized Official

Name: MISS JILL KATHLEEN MASURE
Title or Position: OWNER
Credential: LICSW
Phone: 978-660-0996