Healthcare Provider Details

I. General information

NPI: 1841302585
Provider Name (Legal Business Name): TERESA A RAE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DIMOCK ST
ROXBURY MA
02119-1208
US

IV. Provider business mailing address

435 WARREN ST
ROXBURY MA
02119-1833
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax: 617-442-4088
Mailing address:
  • Phone: 617-442-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5801
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: