Healthcare Provider Details

I. General information

NPI: 1053187443
Provider Name (Legal Business Name): SUNNYSIDE UP COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 11/28/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MARC AVENUE SUITE 1703
SOUTH BRIDGE MA
01550
US

IV. Provider business mailing address

177 HUNTINGTON AVE STE 1703
BOSTON MA
02115-3153
US

V. Phone/Fax

Practice location:
  • Phone: 508-596-0234
  • Fax:
Mailing address:
  • Phone: 508-596-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANIE ANN LIPKA
Title or Position: OWNER/OPERATOR
Credential: LMHC
Phone: 508-596-0234