Healthcare Provider Details

I. General information

NPI: 1801090451
Provider Name (Legal Business Name): MARCO BELLUARDO-CROSBY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

P.O. BOX 526 269 UNION STREET
LYNN MA
01901-1314
US

V. Phone/Fax

Practice location:
  • Phone: 781-581-3900
  • Fax: 781-598-1050
Mailing address:
  • Phone: 781-477-7222
  • Fax: 781-598-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 233936
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number233936
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: