Healthcare Provider Details

I. General information

NPI: 1114012093
Provider Name (Legal Business Name): WANDA T. STEVENS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CENTER ST
GROVELAND MA
01834-1001
US

IV. Provider business mailing address

2 CENTER ST
GROVELAND MA
01834-1001
US

V. Phone/Fax

Practice location:
  • Phone: 978-979-4479
  • Fax: 978-768-2589
Mailing address:
  • Phone: 978-979-4479
  • Fax: 978-768-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1231
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: