Healthcare Provider Details

I. General information

NPI: 1205592482
Provider Name (Legal Business Name): PRINCIPIUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MAIN ST STE 5
STURBRIDGE MA
01566-1556
US

IV. Provider business mailing address

128 MAIN ST STE 5
STURBRIDGE MA
01566-1556
US

V. Phone/Fax

Practice location:
  • Phone: 508-659-8585
  • Fax: 508-659-8586
Mailing address:
  • Phone: 508-659-8585
  • Fax: 508-659-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARYANN MATHIEU
Title or Position: BILLING MANAGER
Credential:
Phone: 508-418-6888