Healthcare Provider Details

I. General information

NPI: 1649825761
Provider Name (Legal Business Name): MR. DEREK ANTHONY CARVALHO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 EAST ST
TEWKSBURY MA
01876-1475
US

IV. Provider business mailing address

890 EAST ST STE 5
TEWKSBURY MA
01876-1475
US

V. Phone/Fax

Practice location:
  • Phone: 781-803-0919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10004793
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: