Healthcare Provider Details

I. General information

NPI: 1235992967
Provider Name (Legal Business Name): HEADWATERS CONSULTING GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 BELMONT ST
SOUTH EASTON MA
02375-1103
US

IV. Provider business mailing address

30 MAPLE ST
BRAINTREE MA
02184-4613
US

V. Phone/Fax

Practice location:
  • Phone: 617-691-0338
  • Fax:
Mailing address:
  • Phone: 617-704-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. KYLE JOHN CRAIG
Title or Position: CO-FOUNDER
Credential:
Phone: 617-704-2391