Healthcare Provider Details

I. General information

NPI: 1346285863
Provider Name (Legal Business Name): CHANNING TAFT MENDELSOHN LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MERRIMACK ST SUITE 200
LOWELL MA
01852-1729
US

IV. Provider business mailing address

45A PARKER ST
WATERTOWN MA
02472-3913
US

V. Phone/Fax

Practice location:
  • Phone: 978-459-2306
  • Fax: 978-453-9394
Mailing address:
  • Phone: 617-926-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number951
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: