Healthcare Provider Details

I. General information

NPI: 1003525486
Provider Name (Legal Business Name): IMAGO PSYCHODYNAMIC COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 WENDELL AVE STE 100
PITTSFIELD MA
01201-7066
US

IV. Provider business mailing address

1032 E BRANDON BLVD # 1023
BRANDON FL
33511-5509
US

V. Phone/Fax

Practice location:
  • Phone: 857-371-8412
  • Fax:
Mailing address:
  • Phone: 857-371-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DANIEL MORENO
Title or Position: MEMBER
Credential: LMHC
Phone: 786-402-7396