Healthcare Provider Details

I. General information

NPI: 1467990846
Provider Name (Legal Business Name): NORTHEAST COUNSELING ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 HAVERHILL ST
METHUEN MA
01844-4203
US

IV. Provider business mailing address

39 HAVERHILL ST
METHUEN MA
01844-4203
US

V. Phone/Fax

Practice location:
  • Phone: 978-804-4068
  • Fax:
Mailing address:
  • Phone: 978-804-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number116999
License Number StateMA

VIII. Authorized Official

Name: MR. SCOTT D WALLACE
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: MSW, LICSW
Phone: 978-804-4068