Healthcare Provider Details

I. General information

NPI: 1578862272
Provider Name (Legal Business Name): LIFE ENHANCEMENT PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 COLUMBIA RD STE 108
HANOVER MA
02339
US

IV. Provider business mailing address

PO BOX 934
HANOVER MA
02339-0934
US

V. Phone/Fax

Practice location:
  • Phone: 617-552-5124
  • Fax:
Mailing address:
  • Phone: 617-552-5124
  • Fax: 888-317-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8649
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number115940
License Number StateMA

VIII. Authorized Official

Name: DR. LESHELLE WOODARD
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 617-552-5124