Healthcare Provider Details

I. General information

NPI: 1275621385
Provider Name (Legal Business Name): FAIRWINDS-NANTUCKETS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 VESPER LN L-1 GOUIN VILLAGE
NANTUCKET MA
02554-4394
US

IV. Provider business mailing address

20 VESPER LN L-1 GOUIN VILLAGE
NANTUCKET MA
02554-4394
US

V. Phone/Fax

Practice location:
  • Phone: 508-228-2689
  • Fax: 508-228-3613
Mailing address:
  • Phone: 508-228-2684
  • Fax: 508-228-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0549
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0549
License Number StateMA

VIII. Authorized Official

Name: MS. JASON BRIDGES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 508-228-2689