Healthcare Provider Details

I. General information

NPI: 1376032623
Provider Name (Legal Business Name): AEON NONPROFIT TRAINING ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 LYNNWAY STE 2C
LYNN MA
01902-3420
US

IV. Provider business mailing address

610 HUMPHREY ST # 1
SWAMPSCOTT MA
01907-2655
US

V. Phone/Fax

Practice location:
  • Phone: 617-982-3996
  • Fax:
Mailing address:
  • Phone: 617-982-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number119679
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number119679
License Number StateMA

VIII. Authorized Official

Name: JENNIFER NAKHAI-ASHTIANI
Title or Position: OWNER/FOUNDER/CEO
Credential: LICSW
Phone: 617-982-3996