Healthcare Provider Details

I. General information

NPI: 1881230407
Provider Name (Legal Business Name): EVAN LAUSELL-RODRIGUEZ MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 TREMONT ST STE 2
ROXBURY CROSSING MA
02120-2193
US

IV. Provider business mailing address

1059 TREMONT ST # 2
ROXBURY CROSSING MA
02120-2149
US

V. Phone/Fax

Practice location:
  • Phone: 617-445-4075
  • Fax:
Mailing address:
  • Phone: 617-445-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13566
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: