Healthcare Provider Details

I. General information

NPI: 1912600511
Provider Name (Legal Business Name): OMEGA THERAPY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 TREMONT ST
MALDEN MA
02148-2717
US

IV. Provider business mailing address

121 TREMONT ST
MALDEN MA
02148-2717
US

V. Phone/Fax

Practice location:
  • Phone: 617-407-0440
  • Fax: 857-302-3179
Mailing address:
  • Phone: 617-407-0440
  • Fax: 857-302-3179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: INES M PIERRE-LOUIS
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 617-407-0440