Healthcare Provider Details

I. General information

NPI: 1104922855
Provider Name (Legal Business Name): STANLEY GAJDA LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N MAIN ST
LEEDS MA
01053-9764
US

IV. Provider business mailing address

13 BAYBERRY DR
EASTHAMPTON MA
01027-2735
US

V. Phone/Fax

Practice location:
  • Phone: 413-230-0869
  • Fax:
Mailing address:
  • Phone: 413-230-0869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6371
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: