Healthcare Provider Details

I. General information

NPI: 1326052317
Provider Name (Legal Business Name): PSYCHOLOGICAL ASSOCIATES OF SOUTHEASTERN MASSACHUSETTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MAIN ST SUITE 2D
NORTH EASTON MA
02356-1468
US

IV. Provider business mailing address

115 MAIN ST SUITE 2D
NORTH EASTON MA
02356-1468
US

V. Phone/Fax

Practice location:
  • Phone: 508-238-7766
  • Fax: 508-230-5089
Mailing address:
  • Phone: 508-238-7766
  • Fax: 508-230-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99999
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9999999
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberXXXXXXX
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number99999
License Number StateMA

VIII. Authorized Official

Name: MS. DIANE L CARLSON
Title or Position: MANAGING PARTNER
Credential: LICSW
Phone: 508-238-7766