Healthcare Provider Details

I. General information

NPI: 1669079729
Provider Name (Legal Business Name): INNER RESOURCES COUNSELING, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 ATLANTIC AVE
MARBLEHEAD MA
01945-3066
US

IV. Provider business mailing address

23 BROOKLINE ST
LYNN MA
01902-1807
US

V. Phone/Fax

Practice location:
  • Phone: 617-501-1083
  • Fax:
Mailing address:
  • Phone: 617-501-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK ACHILLES NICKOLAS
Title or Position: PRESIDENT
Credential: PHD, LMHC
Phone: 617-501-1083