Healthcare Provider Details

I. General information

NPI: 1821262189
Provider Name (Legal Business Name): COMMON GROUND COUNSELING & PERSONAL GROWTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 STEEPLE STREET SUITE 2053
MASHPEE MA
02649
US

IV. Provider business mailing address

22 STEEPLE STREET SUITE 2053
MASHPEE MA
02649
US

V. Phone/Fax

Practice location:
  • Phone: 508-477-3600
  • Fax: 508-477-3711
Mailing address:
  • Phone: 508-477-3600
  • Fax: 508-477-3711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113878
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number160572
License Number StateMA

VIII. Authorized Official

Name: MR. JOSEPH F DOWICK
Title or Position: SOLE MBR
Credential: LICSW
Phone: 508-477-3600