Healthcare Provider Details

I. General information

NPI: 1710133863
Provider Name (Legal Business Name): MARC CLOUGH MED. CAGS LEP LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MAIN ST UNIT 213
MEDWAY MA
02053-1584
US

IV. Provider business mailing address

165 MAIN ST UNIT 213
MEDWAY MA
02053-1584
US

V. Phone/Fax

Practice location:
  • Phone: 508-254-9203
  • Fax: 774-929-9350
Mailing address:
  • Phone: 508-254-9203
  • Fax: 774-929-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7371
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number895
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: